Top 6870 Rn Utilization Management Jobs

Utilization Management and Discharge Planning RN
Santa Clara Family Health Plan —San Jose, CA
- $100,968 - $151,451 a year
- Temporary
- Hybrid work
- Nursing
- Skilled nursing facility
- RN License
- Wellness program
- Health insurance
Quick Apply
17h
Utilization Management Nurse
Applied Underwriters —Omaha, NE
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Paid training
- Paid holidays
Quick Apply
14d
Utilization Review Nurse
University Medical Center of Southern Nevada —Las Vegas, NV
- $40.72 - $63.12 an hour
- Weekends as needed
- Nursing
- RN License
- Office
- Health insurance
- Dental insurance
Quick Apply
Utilization Specialist
RiverWoods Behavioral Health —Riverdale, GA
- Part-time
- CPR Certification
- Nursing
- RN License
SENIOR ANALYST HEALTH HOME
SBH Health System —Bronx, NY
- $110,000 - $114,000 a year
- Full-time
- Background check
- Anatomy knowledge
- Management
- Health insurance
- Dental insurance
Quick Apply
Utilization Management Nurse
Blue Eagle Consulting —Remote
- RN License
- Mid-level
- Nursing
Quick Apply
Utilization Management Registered Nurse
West Coast Consulting —Remote
- $30 - $34 an hour
- Contract
- Remote
- RN License
- Mid-level
- Nursing
- 401(k)
Quick Apply
5d
Utilization Management Nurse Consultant
CVS Health —Florida
- $29.10 - $62.32 an hour
- Weekends as needed
- Remote
- Nursing
- RN License
- Mid-level
- Health insurance
- Dental insurance
14d
Health Nurse - Utilization Management
Alterwood Health —Remote
- $75,000 - $95,000 a year
- Full-time
- Microsoft Word
- Background check
- Nursing
- Health savings account
- Disability insurance
Quick Apply
8d
Utilization Review RN
Memorial Health —Springfield, IL
- $32.95 - $52.73 an hour
- Full-time
- Acute care
- Nursing
- RN License
Utilization Management Nurse
TEXAS INDEPENDENCE HEALTH PLAN INC —Austin, TX
- Weekends as needed
- Hybrid work
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
RN Team Lead Utilization Review
MedStar Health —Clinton, MD
- $89,065 - $162,801 a year
- Full-time
- Hybrid work
- Nursing
- RN License
- Inpatient
Quick Apply
13d
Pool Utilization Review Registered Nurse, Case Management, Per Diem,Shift Varies (Rotating Weekends)
Baptist Health South Florida —Boca Raton, FL
- $47 an hour
- Rotating weekends
- Nursing
- RN License
- Mid-level
- Wellness program
- Health insurance
Utilization Review Nurse
Nora Concierge Care —Syracuse, NY
- $65 an hour
- Contract
- RN License
- BLS Certification
- HIPAA
Quick Apply
5d
Utilization Management Clinician I
Community Health Plan of Washington —Seattle, WA
- $35.92 - $55.67 an hour
- Full-time
- Mid-level
- Analysis skills
- Critical & Intensive Care
- Paid jury duty
- Health savings account
Quick Apply
Medical Management - Utilization Management RN 145-2026
CommunityCare —Remote
- Full-time
- Remote
- Background check
- Nursing
- RN License
Quick Apply
5d
Utilization Review Nurse
Cobalt Benefits Group LLC —Dallas, TX
- $90,000 - $98,000 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Health savings account
- AD&D insurance
Quick Apply
Clinical Auditor I-Nurse
WellSense Health Plan —Remote
- $64,000 - $93,000 a year
- Full-time
- Nursing
- RN License
- Bachelor's degree
- Health insurance
- Dental insurance
Concurrent Utilization Review Nurse, RN
NeueHealth —Los Angeles, CA
- $74,286.15 - $111,429.23 a year
- Remote
- Nursing
- RN License
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
Utilization Review Nurse
Health Business Solutions LLC —Remote
- Remote
- Nursing
- RN License
- Bachelor of Science
7d

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Utilization Management and Discharge Planning RN

Santa Clara Family Health Plan -
San Jose, CA

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Job Details

Temporary
$100,968 - $151,451 a year
17 hours ago

Benefits

Wellness program
Health insurance
On-site gym
Dental insurance
401(k)
Flexible spending account
Tuition reimbursement
Paid time off
Employee assistance program
Vision insurance
401(k) matching
Life insurance
Referral program
Retirement plan

Qualifications

Medicare
Utilization review
Managed care
RN License
Pre-authorization review for utilization management
Case management
Utilization management
Centers for Medicare and Medicaid Services (CMS)
Healthcare compliance

Full Job Description

About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:

The Utilization Management and Discharge Planning Nurse performs clinical review in accordance with applicable regulatory and professional standards for Organization Determination Requests using clinical experience and skills in a collaborative process to assess, plan, implement, coordinate and evaluate options to ensure appropriate utilization of member healthcare services and benefits for all lines-of-business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

Day to Day:

Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective/claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business.
Complete authorization reviews by applying the appropriate clinical criteria/guidelines, policy, procedures and clinical judgment to render coverage determinations.
Document pre-admission status, including living arrangements, physical and mental function, social support, durable medical equipment (DME), and other services received.
Draft appropriate notification letters such as approval, denial, delay and modify notifications to providers and members and language threshold following regulatory requirements..
Perform onsite concurrent review activities, as needed in the home, facility or community setting. For Long Term Care UR RN: Conduct regularly scheduled on-site visits to contracted skilled nursing facilities to follow up on re-admissions, confirm member census, conduct member assessments and provide on-site utilization and concurrent review.
Review and monitor hospital or nursing facility census and internal reports to track, reconcile and update discrepancies in member case files. For Long Term UR RN: Monitor and oversee re-admission and transfer prevention strategy.
Facilitate and coordinate communication related to post discharge with member interdisciplinary care team (ICT) including physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services.
Apply the use of clinical judgment to identify and coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality.
Proactively and collaboratively interface with external case management staff including delegates to facilitate discharge planning and care transitions.
Maintain adherence with Model of Care of CMC, LTSS and DHCS regulatory requirements.

About You:

Active California Board of Nursing License (RN) without restriction.
Minimum one year of licensed related health care experience.
Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management.
Knowledge of MediCal and/or Medicare guidelines and regulations.
One year of experience with a Managed Care Health Plan.
Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards.
Ability to make determinations based on Nursing knowledge when no criteria are available or applicable.
Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance.
Clinical knowledge and critical thinking skills with the ability to assess individualized whole-person care needs necessary to develop an effective care plan.
Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children).

Please review the full job description on our Career’s page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=3170

Job Type: Temporary

Pay: $100,968.00 - $151,451.00 per year

Benefits:

401(k)
401(k) matching
Dental insurance
Employee assistance program
Flexible spending account
Health insurance
Life insurance
On-site gym
Paid time off
Referral program
Retirement plan
Tuition reimbursement
Vision insurance
Wellness program

Application Question(s):

Do you have Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards?
Do you have experience in reviewing clinical criteria to make determinations?

Experience:

licensed related health care: 1 year (Required)
Managed Care Health Plan: 1 year (Preferred)
MediCal and/or Medicare : 1 year (Required)

License/Certification:

RN License (Required)

Work Location: Hybrid remote in San Jose, CA 95119

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