Top 11 Utilization management nurse Jobs in Dorado Pr

Especialista en Revision Medica
MCS HEALTHCARE HOLDINGS, LLC —San Juan, PR
- Spanish
- Nursing
- RN License
Registered Nurse Care Navigator Bilingual English/Spanish
Duo Health —San Juan, PR
- Monday to Friday
- Background check
- Spanish
- Nursing
- Travel reimbursement
- Mileage reimbursement
Quick Apply
Medical Case Manager
Family Medicine Group —Carolina, PR
- $11 - $14 an hour
- Full-time
- Bilingual
- HIPAA
- Mid-level
Quick Apply
4d

More jobs to discover

Find similar jobs that you might be interested in.

Registered Nurse Care Navigator Bilingual English/Spanish
Duo Health —San Juan, PR
Reliable transportation, valid driver's license, and ability to travel to patient homes throughout assigned territory.
Quick Apply

Explore jobs in cities nearby

Check out jobs in cities near your current location, Columbus

RN, LSW, LISW, Care Manager - Columbus
Careforth —Columbus, OH
Ability and flexibility to travel (usually by car) within assigned geographic area; valid driver’s license and car insurance required.
$62,657 - $84,173 a year
Patient Support Nurse
Valeris, Inc. —Columbus, OH
Must have active RN licensure in current state of practice. 2-3 years of nursing experience with relevant disease state experience preferred.
Quick Apply
9d

Show more jobs in cities nearby

I want to receive the latest job alert for utilization management nurse in dorado pr

By signing in to your account, you agree to SimplyHired's Terms of Service and consent to our Cookie and Privacy Policy.

Explore jobs in more locations

utilization management nurse jobs near dorado pr

Case Manager jobs in Carolina, PR

Case Manager jobs in Durham, NC

Category Manager jobs in Remote

Case Manager jobs in Arlington, TX

Case Manager jobs in Edinburg, TX

Case Manager jobs in Las Cruces, NM

Case Manager jobs in Bronx, NY

Case Manager jobs in Kansas City, MO

Care Navigator jobs in Seattle, WA

Care Navigator jobs in Greenville, NC

Patient Care Technician Will Train Part Time jobs in Queens, NY

Patient Care Assistant jobs in Toledo, OH

Patient Care Technician jobs in North Richland Hills, TX

Care Navigator jobs in Salem, VA

Care Navigator jobs in Gainesville, FL

Especialista en Revision Medica

MCS HEALTHCARE HOLDINGS, LLC -
San Juan, PR

Apply Now

Job Details

Qualifications

Nursing
RN License
English
Bachelor of Science in Nursing
Bachelor's degree in nursing
Nursing

Full Job Description

Especialista en Revision Medica

Regular

Exempt

GENERAL DESCRIPTION:

Responsible for conducting clinical reviews of post-service and pre-payment claims requiring medical documentation to determine medical necessity, coding accuracy, reimbursement appropriateness, and compliance with clinical guidelines, payment policies, and regulatory requirements. Applies clinical judgment, critical thinking, and reimbursement knowledge to support accurate claim determinations, cost containment initiatives, and payment integrity.

ESSENTIAL FUNCTIONS:

Conducts clinical reviews and analyses of complex medical records, ancillary services, appeals, and claims requiring clinical documentation to determine medical necessity, coding accuracy, and reimbursement appropriateness, applying clinical judgment and critical thinking in the review of initial determinations and appeals.
Investigates and evaluates claims using applicable systems, clinical guidelines, payment policies, coding rules, and provider agreements to support accurate determination and payment integrity, integrating knowledge of reimbursement to ensure accurate claim outcomes.
Performs clinical and telephonic interventions with providers to validate medical necessity, request additional documentation, discuss clinical scenarios, and support claim determinations, providing guidance and sharing knowledge with providers and internal stakeholders regarding clinical determinations and documentation requirements.
Identifies cost-containment opportunities, inappropriate billing patterns, overpayments, and potential fraud, waste, or abuse situations, escalating cases when applicable, including evaluation of cost drivers such as high-cost diagnostics, transportation, and NCCI-related edits, supporting cost savings initiatives.
Documents case findings, recommendations, rationales, and referral information accurately while maintaining evidence and records according to departmental standards, ensuring documentation meets audit and compliance requirements.
Collaborates with internal departments and participates in meetings, projects, and operational initiatives to support service quality, compliance, and effective claims review operations.
Refers cases to Medical Policy or other appropriate departments when clinical review identifies policy gaps or requires further evaluation.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and experience: Bachelor's degree in Nursing Sciences. At least two (2) years of clinical nursing experience required. Experience in utilization review, payment integrity, claims review, case management, managed care, or healthcare reimbursement operations preferred. Knowledge of CMS guidelines, coding methodologies, and medical necessity review processes preferred.

Certifications / Licenses: A valid License and Registration of Nurse & Association Nursing Professionals of Puerto Rico are required.

Other: Extensive knowledge of medical terminology and experience in ICD-10 and CPT coding is preferred.

Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)

“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”

Apply Now

Refine Your Search

utilization management nurse jobs in dorado pr

Especialista en Revision Medica

Registered Nurse Care Navigator Bilingual English/Spanish

Medical Case Manager

More jobs to discover

Explore jobs in cities nearby

I want to receive the latest job alert for utilization management nurse in dorado pr

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected