Top 52 Utilization review Jobs in Pittsburgh, Pa

UM Care Manager (RN)
UPMC —Pittsburgh, PA
- $34.49 - $56.83 an hour
- Full-time
- Nursing
- RN License
- Computer literacy
- Work from home
4h
Registered Nurse - Community Care Coordinator
US Veterans Health Administration —Allegheny County, PA
- $71,798 - $147,862 a year
- Online Application
- Background check
- Nursing
- Doctoral degree
- Paid holidays
- Dental insurance
6d
Mobile Professional Care Manager - Allegheny County
UPMC —Pittsburgh, PA
- $29.29 - $48.21 an hour
- Full-time
- LMFT
- Nursing
- RN License
- Flexible schedule
RN Case Manager (Full Time)- AHN Wexford
Allegheny Health Network —Wexford, PA
- Full-time
- CPR Certification
- Nursing
- 6 years
Case Manager - Full Time Exempt
Pennsylvania Organization for Women in Early Recovery —Swissvale, PA
- Full-time
- HIPAA
- Mid-level
- Outpatient experience
- Paid holidays
- Disability insurance
Quick Apply
RN Case Manager
Community LIFE —Homestead, PA
- $72,000 - $85,000 a year
- Full-time
- Nursing
- RN License
- Word processing
- Travel reimbursement
- Mileage reimbursement
Quick Apply
14d
RN Case Manager
Community LIFE —Wilkinsburg, PA
- $72,000 - $85,000 a year
- Full-time
- Nursing
- RN License
- Word processing
- Travel reimbursement
- Mileage reimbursement
Quick Apply
7d
Clinic Manager
Allegheny County Pennsylvania —Allegheny County, PA
- $90,000 a year
- Online Application
- Background check
- CPR Certification
- Nursing
Mobile Professional Care Manager - Beaver & Lawrence Counties
UPMC —Pittsburgh, PA
- $29.29 - $48.21 an hour
- Full-time
- LMFT
- Nursing
- RN License
RN Care Coordinator, AVH, Full Time
Allegheny Health Network —Natrona Heights, PA
- Full-time
- CPR Certification
- Nursing
- RN License
Minimum Data Set (MDS) Coordinator
Allegheny County Pennsylvania —Allegheny County, PA
- $40.75 an hour
- Online Application
- Background check
- Nursing
- Skilled nursing facility
Substance Abuse Case Manager
Pinnacle Treatment Centers —Pittsburgh, PA
- Addiction Medicine
- Mid-level
- Driver's License
- Loan repayment program
- Disability insurance
Quick Apply
Medical Case Manager I
CorVel Corporation —Pittsburgh, PA
- $63,739 - $95,264 a year
- Full-time
- Remote
- Nursing
- RN License
- Computer literacy
- Health savings account
- Disability insurance
Quick Apply
7d
Medical Director, Utilization Management
UPMC —Pittsburgh, PA
- Full-time
- Medicine
- Management
- 5 years
- Health insurance
- Opportunities for advancement
RN Case Manager (Full Time, 40 Hours), West Penn Hospital
Allegheny Health Network —Pittsburgh, PA
- Full-time
- CPR Certification
- Nursing
- 6 years
- Free parking
- Commuter assistance
Mobile Professional Care Manager - Mercer & Venango Counties
UPMC —Pittsburgh, PA
- $29.29 - $48.21 an hour
- Full-time
- LMFT
- Nursing
- RN License
RN Case Manager Inpatient, Allegheny General
Allegheny Health Network —Pittsburgh, PA
- Full-time
- CPR Certification
- Nursing
- 6 years
Mobile Professional Care Manager (RN) - Butler County
UPMC —Pittsburgh, PA
- $29.29 - $48.21 an hour
- Full-time
- LMFT
- Nursing
- Surgery
- Flexible schedule
Clinical Pharmacy Specialist- Ambulatory Forbes Family Medicine/Care Partner Clinic
Allegheny Health Network —Monroeville, PA
- Full-time
- Hybrid work
- Patient monitoring
- Mid-level
- Clinic
Care Manager
Trilogy Wellness LLC —Monroeville, PA
- $18 - $21 an hour
- Full-time
- Addiction Medicine
- Writing skills
- Mid-level
Quick Apply

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utilization review jobs near pittsburgh, pa

UM Care Manager (RN)

UPMC -
Pittsburgh, PA

Apply Now

Job Details

Full-time
$34.49 - $56.83 an hour
4 hours ago

Benefits

Work from home

Qualifications

Computer operation
Managing patients as a nurse case manager
Utilization management
Resource utilization in healthcare
Computer skills

Full Job Description

Are you a registered nurse with a background in utilization management? UPMC Health Plan is looking for you!

We are hiring a full-time Utilization Management Care Manager to support the Utilization Management Clinical Operations Department. This position will predominantly work from home, standard daylight hours, Monday through Friday.

The Utilization Management (UM) Care Manager is responsible for utilization review of health plan services and assessment of member's barriers to care. Interacts daily with facility clinicians, physicians, and UPMC Health Plan care managers and Medical Directors as part of the member treatment team. Provides guidance and assistance to providers and members to ensure that health care needs are met through the delivery of covered services in the most appropriate setting and cost - effective manner.

Responsibilities:

Obtain documentation to support requested level of care within the defined health plan regulatory timeframes and provide verbal and/or written notification to providers as applicable. Consult with health plan medical director to discuss medical necessity for requested service.
Document all activities in the Health Plan's care management tracking system following Health Plan and internal department standards and identify trends and opportunities for improvement based on information obtained from interaction with members and providers.
Review and document clinical information from health care providers including clinical history, home environment, support system, available caregiver, cognitive and psychological status. Conduct clinical reviews for authorization requests using established criteria including Interqual, Mahalik, and health plan policy and procedures for inpatient, outpatient, Durable Medical Equipment (DME), Behavioral Health, and Private Duty Nursing.
Participate in health plan interdisciplinary team conferences and collaborative case reviews to discuss complex cases and determine appropriate discharge plan or level of service. Consult with health plan medical director on an as needed basis to discuss medical necessity for requested service.
Work closely with peers and other departments to determine discharge needs including necessary referrals to health plan care management for short- or long-term interventions.
Maintain communication with health care providers regarding health plan determinations.
Identify potential quality of care concerns and never events and refers to health plan quality management department.

Minimum of 2 years of experience in a clinical and/or case management nursing required.
Minimum of 1-year work-related experience in Utilization Management required.
Experience with prior authorizations preferred.
PA RN license preferred.

Strong organizational, task prioritization and problem-solving skills.
Ability to construct grammatically correct reviews using standard medical terminology.
Computer proficiency required.

Licensure, Certifications, and Clearances:
Case management certification or approved clinical certification preferred
Registered Nurse (RN)
Act 34
Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran

Apply Now

Refine Your Search

utilization review jobs in pittsburgh, pa

UM Care Manager (RN)

Registered Nurse - Community Care Coordinator

Mobile Professional Care Manager - Allegheny County

RN Case Manager (Full Time)- AHN Wexford

Case Manager - Full Time Exempt

RN Case Manager

RN Case Manager

Clinic Manager

Mobile Professional Care Manager - Beaver & Lawrence Counties

RN Care Coordinator, AVH, Full Time

Minimum Data Set (MDS) Coordinator

Substance Abuse Case Manager

Medical Case Manager I

Medical Director, Utilization Management

RN Case Manager (Full Time, 40 Hours), West Penn Hospital

Mobile Professional Care Manager - Mercer & Venango Counties

RN Case Manager Inpatient, Allegheny General

Mobile Professional Care Manager (RN) - Butler County

Clinical Pharmacy Specialist- Ambulatory Forbes Family Medicine/Care Partner Clinic

Care Manager

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