Top 52 Utilization review nurse Jobs in Tempe, 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
10d
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
7d
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
7d
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
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
12d
Nurse Care Coordination
St Joseph Hospital & Medical Center —Phoenix, AZ
- $39.18 - $58.28 an hour
- Full-time
- Nursing
- RN License
- Inpatient
9d
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 RN Patient Navigator Neurology Clinic
Banner Health —Mesa, AZ
- Part-time
- Background check
- Nursing
- RN License
- Wellness program
- Employee assistance program
6d
Supervisor, Utilization Review (TOC) - Hybrid
Blue Cross Blue Shield of Arizona —Phoenix, AZ
- Full-time
- Microsoft Word
- Nursing
- RN License
RN Case Manager Shea
HonorHealth —Scottsdale, AZ
- Full-time
- Acute care
- Nursing
- RN License
Nurse Navigator
Arizona Specialty Hospital (11101) —Phoenix, AZ
- Full-time
- Nursing
- Surgery
- RN License
- Health savings account
- Paid holidays
RN Care Manager
Arizona Priority Care —Chandler, AZ
- $45 - $47 an hour
- Full-time
- Hybrid work
- Nursing
- Clean driving record
- RN License
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 (RN) - Case Manager
Abrazo Scottsdale Campus —Phoenix, AZ
- Full-time
- Acute care
- Nursing
- RN License
- Health savings account
- Health insurance
6d
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
RN Care Manager - Phoenix Market (Peoria/North MNT)
ArchWell Health —Phoenix, AZ
- Full-time
- Nursing
- RN License
- Mid-level
6d
Quality Nurse – QAPI Coordinator
Innovative Health Care —Scottsdale, AZ
- $75,000 - $85,000 a year
- Full-time
- Nursing
- RN License
- Bachelor of Science
Quick Apply
Psych Nurse Practitioner - Crisis - Multiple Site
Community Bridges, INC —Phoenix, AZ
- Email
- CPR Certification
- Nursing
- Psychiatry
- Disability insurance
- Health insurance
Quick Apply
Psych Nurse Practitioner - Non-Crisis - Phoenix, Mesa, Avondale
Community Bridges, INC —Mesa, AZ
- Email
- CPR Certification
- Nursing
- Psychiatry
- Disability insurance
- Health insurance
Quick Apply

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RN Case Manager - Utilization Review

The CORE Institute Specialty Hospital -
Phoenix, AZ

Quick Apply

Job Details

10 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.

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Refine Your Search

utilization review nurse jobs in tempe, az

RN Case Manager - Utilization Review

Utilization Review Registered Nurse, Care Coordinator

Sr. Quality of Care Review Nurse

Utilization Management Clinical Reviewer

ABA Clinical Reviewer

Nurse Care Coordination

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

Travel Nurse Patient Logistics

Registered Nurse RN Patient Navigator Neurology Clinic

Supervisor, Utilization Review (TOC) - Hybrid

RN Case Manager Shea

Nurse Navigator

RN Care Manager

Registered Nurse - Case Manager Inpatient - RN

Registered Nurse (RN) - Case Manager

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

RN Care Manager - Phoenix Market (Peoria/North MNT)

Quality Nurse – QAPI Coordinator

Psych Nurse Practitioner - Crisis - Multiple Site

Psych Nurse Practitioner - Non-Crisis - Phoenix, Mesa, Avondale

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