Top 56 Utilization review Jobs in Pittsburgh Pa

Quality of Care Clinical Coordinator I (RN) - Hybrid
UPMC - Pittsburgh Medical Center —Pittsburgh, PA
- $32.85 - $56.83 an hour
- Full-time
- Nursing
- RN License
- Computer literacy
23h
Home Care Coordinator - COTA/L
Community LIFE —McKeesport, PA
- $25 - $30 an hour
- Full-time
- Word processing
- Computer literacy
- Mid-level
- Mileage reimbursement
- Paid holidays
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
5d
Clinical Staff Pharmacist
Zeal Specialty Pharmacy —Pittsburgh, PA
- Full-time
- Bachelor of Science
- Office
- Bachelor's degree
- Health insurance
- Dental insurance
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
Therapist (Full Time or Part Time)
CHARTIERS CENTER —Carnegie, PA
- Part-time
- Addiction Medicine
- LPC
- Mid-level
- Paid holidays
- Disability insurance
Quick Apply
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
Part-Time Nursing Case Manager - Skilled Nursing
Concordia at Villa St. Joseph —Baden, PA
- From $34 an hour
- Part-time
- Background check
- Skilled nursing facility
- RN License
- 401(k)
- Paid time off
Quick Apply
8d
RN Case Manager - Home Health
Interim HealthCare —Coraopolis, PA
- $80,000 - $95,000 a year
- Full-time
- CPR Certification
- Management
- RN License
Quick Apply
Quality of Care Clinical Coordinator I (RN) - Hybrid
UPMC —Pittsburgh, PA
- $32.85 - $56.83 an hour
- Full-time
- Nursing
- RN License
- Computer literacy
1d
Hospital Services Coordinator
The Children's Home of Pittsburgh —Pittsburgh, PA
- $23 - $28 an hour
- Full-time
- Inpatient
- Mid-level
- High school diploma or GED
- Free parking
- Disability insurance
Quick Apply
11d
Medical Director, Utilization Management
UPMC —Pittsburgh, PA
- Full-time
- Remote
- Medicine
- Management
- 5 years
- Opportunities for advancement
Clinic Manager
Allegheny County Pennsylvania —Allegheny County, PA
- $90,000 a year
- Online Application
- Background check
- CPR Certification
- Nursing
RN Case Manager (Part Time) - West Penn Hospital
Allegheny Health Network —Pittsburgh, PA
- Part-time
- CPR Certification
- Nursing
- 6 years
Finance Manager - Revenue Cycle
Devereux —Braddock, PA
- $70,000 - $79,800 a year
- Full-time
- 5 years
- Pass drug screening
- Office
- Paid training
- 403(b) matching
Drug & Alcohol Therapist
Sojourner House —Pittsburgh, PA
- $48,000 - $58,000 a year
- Full-time
- Nursing
- Current TB test
- Addiction Medicine
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
RN Case Manager (Full Time)- AHN Wexford
Allegheny Health Network —Wexford, PA
- Full-time
- CPR Certification
- Nursing
- 6 years
16h
RN Case Manager Inpatient, Allegheny General
Allegheny Health Network —Pittsburgh, PA
- Full-time
- CPR Certification
- Nursing
- 6 years
Case Manager Counselor Sub Rec Unit Mon Valley Hospital
Penn Highlands Healthcare —Monongahela, PA
- Full-time
- Hospital
- Mid-level
- Master's degree
- Free parking
- Disability insurance
Quick Apply

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Quality of Care Clinical Coordinator I (RN) - Hybrid

UPMC - Pittsburgh Medical Center -
Pittsburgh, PA

Apply Now

Job Details

Full-time
$32.85 - $56.83 an hour
23 hours ago

Qualifications

Direct patient care
RN License
Computer skills
Patient treatment

Full Job Description

UPMC Health Plan is hiring a full-time Quality of Care Clinical Coordinator I to join the Quality Improvement team. This role will predominantly work remotely but will require in office presence once a month in downtown Pittsburgh's US Steel Tower.

This position coordinates and completes quality-of-care investigations, ensuring timely and compliant resolution across all intake channels. Manages multiple cases concurrently, conducts data analysis to identify quality improvement opportunities, and collaborates with Medical Directors and cross-functional teams through case review, documentation, administrative determinations, and case closure. This role supports regulatory compliance across all lines of business within the Quality Improvement department.

Responsibilities:

Review, investigate, and complete case investigation related to quality-of-care concerns in required timeframes.
Work closely with Special Investigations Unit (SIU), Network, Claims, Community Care Behavioral Health, Provider Services, Member Services, Medical Management, and Pharmacy Services to ensure review processes are understood and meet Health Plan strategy for appropriateness of quality-of-care referrals.
Manage escalated member and provider issues as required.
Review referrals for quality-of-care concerns, completes a comprehensive investigation summarizing clinical facts for the Medical Director review.
Coordinates timely case review by a Health Plan Medical Director.
Create correspondence for review prior to finalizing outreach to providers as needed to obtain and review additional clinical documentation, as well as provider and/or facility responses.
Interpret Medical Director notes and summarize into correspondence for provider and/or facility.
Report trends to leadership for improvement opportunities and provider education.
Prepare documentation and summary for physician consultant peer review packets for designated specialized cases (i.e., pediatric neurosurgery) outline case and peer review needs
Outreach to providers as appropriate to communicate decision.
Collaborate with health plan business partners, as appropriate, for referral of investigation
Build and foster collaborative relationships with internal and external stakeholder
Assist in the creation, enhancement, and implementation of process workflows for the QI, QOC Department.
Assist with identifying continuing education needs and opportunities; maintain continuing education and appropriate CEUS required for RN licensure.
Participate in quality improvement initiatives as assigned

Registered nurse with a minimum of two years direct patient care experience required. PA RN license preferred.
Two years of Health Insurance experience as a Registered Nurse in a Utilization Management/Medical Management/Care Management role strongly preferred.
BSN is a bonus.
HEDIS knowledge is a bonus.
Experience with accountability for regulatory compliance for entities such as NCQA, CMS, Department of Public Welfare, Department of Health, and/or Pennsylvania Insurance Department preferred.
Excellent verbal and written communications skills required.
The ability to work in a fast-paced insurance environment and to manage multiple priorities/projects in a professional manner required.
Working knowledge of ICD-9/ICD-10 and CPT classifications and coding of diagnoses and procedures preferred.
Proficiency in computer skills required.
Ability to collaborate effectively with physicians and other health care professionals.
Strong organizational and critical thinking skills with ability to make decisions independently.

Licensure, Certifications, and Clearances:
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

Quality of Care Clinical Coordinator I (RN) - Hybrid

Home Care Coordinator - COTA/L

RN Case Manager

Clinical Staff Pharmacist

RN Case Manager

Therapist (Full Time or Part Time)

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

Part-Time Nursing Case Manager - Skilled Nursing

RN Case Manager - Home Health

Quality of Care Clinical Coordinator I (RN) - Hybrid

Hospital Services Coordinator

Medical Director, Utilization Management

Clinic Manager

RN Case Manager (Part Time) - West Penn Hospital

Finance Manager - Revenue Cycle

Drug & Alcohol Therapist

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

RN Case Manager (Full Time)- AHN Wexford

RN Case Manager Inpatient, Allegheny General

Case Manager Counselor Sub Rec Unit Mon Valley Hospital

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