Top 59 Utilization review nurse Jobs in Scottsdale Az

RN Case Manager - Utilization Review
The CORE Institute Specialty Hospital —Phoenix, AZ
- Nursing
- RN License
- Bachelor of Science
- Health savings account
- Health insurance
Quick Apply
5d
Utilization Review Registered Nurse, Care Coordinator
US Veterans Health Administration —Phoenix, AZ
- $89,703 - $166,144 a year
- Online Application
- Background check
- Nursing
- Doctoral degree
- Paid holidays
- Dental insurance
2d
Utilization Management Clinical Reviewer
TriWest Healthcare Alliance —Phoenix, AZ
- $88,000 - $93,000 a year
- Overtime
- Microsoft Excel
- Microsoft Outlook
- RN License
- AD&D insurance
- Disability insurance
BH UM Clinical Reviewer- Remote AZ
Blue Cross Blue Shield of Arizona —Phoenix, AZ
- Full-time
- Mid-level
- Organizational skills
- 1 year
ABA Clinical Reviewer
TriWest Healthcare Alliance —Phoenix, AZ
- $79,000 - $93,000 a year
- Full-time
- Microsoft Outlook
- Customer service
- Computer literacy
- AD&D insurance
- Disability insurance
7d
TRICARE Clinical Quality Reviewer
TriWest Healthcare Alliance —Phoenix, AZ
- $79,000 - $93,000 a year
- Overtime
- Nursing
- Microsoft Excel
- Microsoft Outlook
- AD&D insurance
- Disability insurance
6d
Sr. Quality of Care Review Nurse
Oscar Health —Tempe, AZ
- $83,628.00 - $109,761.75 a year
- Remote
- Spanish
- Nursing
- RN License
- Paid parental leave
- Paid holidays
Quick Apply
2d
Supervisor, Utilization Review (TOC) - Hybrid
Blue Cross Blue Shield of Arizona —Phoenix, AZ
- Full-time
- Microsoft Word
- Nursing
- RN License
High-Cost Claimant Review Unit Nurse Auditor (Remote in AZ)
Blue Cross Blue Shield of Arizona —Phoenix, AZ
- Full-time
- 5 years
- Analysis skills
- Travel
Travel Nurse Patient Logistics
Dignity Health —Phoenix, AZ
- $20 - $80 an hour
- Full-time
- Nursing
- RN License
- Hospital
Registered Nurse - Case Manager Inpatient - RN ED/OBS/ACH *Part Time*
Mayo Clinic —Phoenix, AZ
- $90,604.80 - $136,011.20 a year
- 12 hour shift
- Nursing
- RN License
- BLS Certification
- Health savings account
- Health insurance
Registered Nurse - Case Manager Inpatient - RN
Mayo Clinic —Phoenix, AZ
- $90,604.80 - $136,011.20 a year
- Weekends as needed
- Nursing
- RN License
- Hospital
- Health savings account
- Health insurance
Registered Nurse (Skilled Unit)
Agave Grove Post Acute —Glendale, AZ
- $39 - $45 an hour
- 12 hour shift
- Experience working with individuals with developmental disabilities
- Nursing
- Skilled nursing facility
- Health savings account
- Health insurance
Quick Apply
12d
RN Care Management Coordinator Pool
Valleywise Health System —Phoenix, AZ
- $49 an hour
- Day shift
- Nursing
- RN License
- Hospital
Quick Apply
Dual-Certified FNP/PMHNP
CareLock, LLC —Phoenix, AZ
- $145,000 - $155,000 a year
- Full-time
- Remote
- CPR Certification
- Nursing
- Psychiatry
- Health insurance
- Dental insurance
Quick Apply
1d
RN (Hospice Case Manager)
Wings of Hope Hospice and Palliative Care —Phoenix, AZ
- $75,000 - $85,000 a year
- Full-time
- Nursing
- RN License
- HIPAA
- Mileage reimbursement
- Health insurance
Quick Apply
RN Care Management Coordinator Pool
Valleywise Health System —Phoenix, AZ
- $49 an hour
- Per diem
- Nursing
- RN License
- English
Quick Apply
RN Hospice Case Manager (EAST)
Dignity Hospice —Phoenix, AZ
- Full-time
- RN License
- HIPAA
- Mid-level
- Health insurance
- Dental insurance
Quick Apply
RN Case Manager Shea
HonorHealth —Scottsdale, AZ
- Full-time
- Acute care
- Nursing
- RN License
Nurse Care Coordination
St Joseph Hospital & Medical Center —Phoenix, AZ
- $39.18 - $58.28 an hour
- Full-time
- Nursing
- RN License
- Inpatient
5d

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RN Case Manager - Utilization Review

The CORE Institute Specialty Hospital -
Phoenix, AZ

Quick Apply

Job Details

5 days ago

Benefits

Health savings account
Health insurance
Employee assistance program
401(k) matching
Food provided

Qualifications

Direct patient care
RN License
Acute care facility experience
Associate's degree
Associate Degree in Nursing

Full Job Description

At The CORE Institute, we are dedicated to taking care of you so you can take care of business! Our robust benefits package includes the following:

Competitive Health & Welfare Benefits
Monthly $43 stipend to use toward ancillary benefits
HSA with qualifying HDHP plans with company match
401k plan with company match (Part-time employees included)
Employee Assistance Program that is available 24/7 to provide support
Employee Appreciation Days
Free Lunch Fridays
Closed Holidays

Key Responsibilities:

A Case Manager/Utilization Review Nurse, in collaboration with patients/families, physicians and the interdisciplinary team, provides leadership and advocacy in the coordination of patient-centered care across the continuum to facilitate optimal transitions and progression in care.

Conduct concurrent and retrospective reviews of patient medical records to verify the medical necessity of services provided.
Assess admission criteria and length of stay, applying standardized clinical guidelines such as InterQual or MCG to justify care levels.
Issue pre-authorizations for procedures, medications, and durable medical equipment by providing clinical information to insurance carriers.
Collaborate with physicians and other healthcare providers to discuss patient care plans and ensure alignment with coverage policies.
Facilitate communication between medical staff and payers to resolve issues related to treatment plans and reimbursement.
Identify and refer cases to case management or social work for complex discharge planning needs.
Prepare and submit clinical appeals to insurance companies when services are denied, providing documentation to support medical necessity.
Track and analyze utilization data to identify trends in resource use, care delays, and claim denials for reporting purposes.

EDUCATION

Associate Degree in Nursing (ADN) required,
Bachelor of Science in Nursing (BSN) preferred.

EXPERIENCE

Three to five years of clinical experience in a direct patient care setting within an acute care hospital required.
Previous experience in case management or utilization management required.

REQUIREMENTS

A current and unrestricted Arizona Registered Nurse (RN) license.
Certification in Health Care Quality and Management (HCQM) or as a Certified Case Manager (CCM) credential preferred.

KNOWLEDGE

Medical Necessity Analysis: This skill involves a detailed evaluation of patient medical records. The nurse must critically assess the documented clinical information to determine if the proposed treatments, procedures, and services are medically appropriate and necessary according to established standards.
Payer-Provider Liaison: Acting as a crucial communication link, the nurse must effectively mediate between healthcare providers and insurance payers. This requires translating clinical information into the language of insurance requirements to resolve discrepancies and pre-emptively address potential denials.
Utilization Data Interpretation: This involves collaborating with the Revenue Cycle Management (RCM) team to analyze utilization data to spot trends, such as patterns in claim denials, delays in care, or inefficient use of resources. This analysis helps inform process improvements and strategic reporting within the healthcare facility.

SKILLS

Patient Assessment: Conduct comprehensive assessments of patients' medical, emotional, and social needs to develop individualized discharge plans that ensure continuity of care.
Care Coordination: Collaborate with healthcare providers, including doctors, nurses, and therapists, to create an integrated plan of care that addresses clinical needs, equipment, home care, and other requirements.
Discharge Planning: Determine the appropriate discharge disposition based on factors such as living situation, mobility, cognitive status, and available support systems. This includes deciding whether patients can return home with services or require care in a facility.
Arranging Services: Coordinate necessary post-discharge services, such as home health care, rehabilitation, and durable medical equipment, ensuring that these services are in place before the patient leaves the hospital.
Communication: Maintain clear communication with all parties involved in the patient's care, including insurance providers, to secure coverage for post-discharge services and ensure that receiving providers are informed of the patient's needs and changes in their condition.
Clinical Guideline Application: Applying standardized clinical criteria, such as InterQual or MCG, is a core function. This involves interpreting complex medical information and using these evidence-based guidelines to objectively justify admission, continued stays, and the appropriate level of care.

ABILITIES

Ability to work in a high-stress, fast-paced environment.
Ability to develop relationships with providers, staff, patients, families, and payors.
Ability to work cooperatively and professionally in a team environment.

Licenses & Certifications

Required

Registered Nurse

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.

Quick Apply

Refine Your Search

utilization review nurse jobs in scottsdale az

RN Case Manager - Utilization Review

Utilization Review Registered Nurse, Care Coordinator

Utilization Management Clinical Reviewer

BH UM Clinical Reviewer- Remote AZ

ABA Clinical Reviewer

TRICARE Clinical Quality Reviewer

Sr. Quality of Care Review Nurse

Supervisor, Utilization Review (TOC) - Hybrid

High-Cost Claimant Review Unit Nurse Auditor (Remote in AZ)

Travel Nurse Patient Logistics

Registered Nurse - Case Manager Inpatient - RN ED/OBS/ACH Part Time

Registered Nurse - Case Manager Inpatient - RN

Registered Nurse (Skilled Unit)

RN Care Management Coordinator Pool

Dual-Certified FNP/PMHNP

RN (Hospice Case Manager)

RN Care Management Coordinator Pool

RN Hospice Case Manager (EAST)

RN Case Manager Shea

Nurse Care Coordination

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