Milliman Utilization Management Jobs Remote Jobs in Usa
7 positions found
L
Manager, Case Management (RN)
Salary not disclosed
The working Manager of Case Management is responsible for the development of staff and systems to effectively operate a comprehensive Case Management Program. Provides leadership and supervision to case managers, social workers, case management coordinators/discharge planners, utilization review coordinators and utilization review technicians. Assesses needs and plans, communicates and designs services that are appropriate to the hospital mission and patient/family needs. Integrates and coordinates services using continuous quality improvement tools.
Required qualifications:
1. Licensed RN in PA.
2. Minimum 5 years’ experience in a Case Management position.
3. Must have analytical ability for problem identification and assessment and evaluation of data/statistics obtained from an on-going review process.
4. Experience and knowledge in basic to intermediate computer skills.
Preferred qualifications:
1. Certification in Case Management, BS or BSN or related field preferred.
2. Current BCLS certificate preferred.
3. Knowledge of Milliman Criteria and InterQual Criteria preferred.
Not Specified
S
Clinical Review Clinician - Appeals
Salary not disclosed
Position Title: Clinical Review Clinician - Appeals
Work Location: Remote - Nationally sourced (Preference for 2 candidates in AZ)
Assignment Duration: 6 months
Work Schedule: 8:00 AM - 5:00 PM EST or CST
Work Arrangement: Remote
Position Summary
Schedule is 8-5 EST or CST hours. Staff will work when there are members of the supervisor/leadership on.
Cases are assigned in round robin fashion for staff to review and work.
Background & Context
The Organization's clinical team handles various types of authorization and claim review requests from various markets nationwide, processing clinical reviews to ensure members have the best outcomes and access to care needed.
Key Responsibilities
Nurses review case files, add, update or edit authorizations.
Work closely with the MD team to make final decisions on cases.
Process clinical reviews to ensure members have access to care needed.
Help reduce provider abrasion by processing retrospective claim reviews.
Work closely with supervisors, senior clinicians, and the coordinator team on end-to-end case processes.
Participate in team collaboration via Teams group chats for routine questions.
Qualification & Experience
Education/Certification (Required): Associate in nursing, Bachelor's in nursing or higher.
Licensure (Required): RN, LPN
Licensure (Preferred): LVN
Must haves:
Medicare knowledge
InterQual or Milliman Experience
Clinical reviews for Utilization Management or Appeals
Nice to haves:
Medicare Appeals Experience
Disqualifiers:
Not having a valid/active RN/LPN license
Performance indicators:
Productivity expectations vary based on platform.
Prime: 7 CPD
iCP: 9 CPD
CenPas: 20 CPD cases per day
95% quality on all cases
Candidate Requirements
Education/Certification
Required: Associate in nursing, Bachelor's in nursing or higher.
Preferred:
Licensure
Required: RN, LPN
Preferred: LVN- Years of experience required
- Disqualifiers
- Best vs. average
- Performance indicators
Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals
Nice to haves: Medicare Appeals Experience
Disqualifiers: Not having a valid/active RN/LPN license
Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases
Best vs. average: Productivity expectations are set based on platform.- Top 3 must-have hard skills
- Level of experience with each
- Stack-ranked by importance
- Candidate Review & Selection
1
Utilization Management or Appeals review background (1 plus year)
2
Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)
3
Retrospective claims clinical reviews (1 plus year)
Not Specified
RN Patient Care Navigator
Salary not disclosed
Hourly Pay Range:
$40.45 - $62.70 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.
Position Highlights:
* Position: RN Patient Care Navigator
* Location: Skokie, IL
* Full Time: 40 hours
* Hours: Monday-Friday, 8:00a-4:30p rotating every 3rd weekend
* I winter holiday (Thanksgiving, Christmas, New Year) and 1 summer (Labor Day, July 4th, Memorial Day) coverage
* Required Travel: Highland Park, Glenbrook, Evanston, Swedish based on clinical needs, less than 1%
A Brief Overview:
The RN Transitional Care Navigator (Population Health) is responsible for the case management, care coordination management, and utilization management of his/her population of patients across multiple care levels and settings. Serves as a catalyst to promote patients understanding their diagnosis, treatment options, and available resources and ensure that they are connected with the optimal resources across the continuum of care. This role will coordinate and facilitate smooth and safe care transitions while ensuring quality cost-effective patient outcomes. Serves as a liaison between their patient population and all other providers. Will be responsible for key metrics of success, which include improving the overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30-day readmission rate and ED utilization.
What you will do:
* Guides high-risk patient and family through the health system from diagnosis, testing, treatment and follow-up care to assist patients with navigating the continuum of care. Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
* Establishes and documents an individualized plan of care for assigned patients using evidence-based treatment guidelines considering the patients individual health goals with a focus on wellness, health management, disease prevention and chronic disease management.
* Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
* Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
* Acts as advisor/educator by partnering with social work in providing emotional support including goals of care and counseling. Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision-making.
* Facilitates appointments for appropriate consultations and support services within established protocols
* Completes Utilization Management for assigned patients.
* Applies Milliman Care Guidelines (Indicia) criteria to monitor appropriateness of admissions and continued stays and documents findings based on Department standards.
* Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
* May need to travel to visit the patient at home from time to time.
* Available to his/her assigned patient population and participates as part of a call coverage structure.
* Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.
*
What you will need:
* Bachelors Degree Health Administration Required Or
* Bachelors Degree Nursing Required
* 3 Years Utilization review, discharge planning, case management or disease management preferred. Nursing experience in home services, ambulatory services working with high-risk patients beneficial.
* 2 Years Clinical nursing experience preferred.
* Adheres to and practices in alignment with contemporary standards of care as established by leading professional organizations, including but not limited to the American Academy of Ambulatory Care Nursing (AAACN), the American Case Management Association (ACMA), and the Case Management Society of America (CMSA).
* Interacts with and contributes to professional development of peers and other health care providers as colleagues. Shares knowledge and provides feedback with peers to contribute to an environment supportive of clinical education.
* Knowledge of InterQual or MCG criteria preferred.
* Clinical certification, such as case management certification, is beneficial.
* Able to communicate and work collaboratively with a range of stakeholders and team members.
* Knowledge of community resources.
* Experience with Microsoft Office Suite.
* Strong interpersonal and oral communication skills.
* Strong computer and data entry skills.
* Experience with Electronic Medical Record (EMR) platform preferred.
* Proven leadership skills.
* Ability to work independently, setting priorities to coordinate care plan efficiently.
* Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Required And
* Certified Case Manager (CCM?) - Commission for Case Manager Certification (CCMC) Preferred Or
* Ambulatory Care Nursing (RN-BC) - American Nurses Credentialing Center (ANCC) Preferred And
* BLS - Basic Life Support (CPR and AED) - American Heart Association (AHA) Required
Benefits (for full and part time positions):
* Premium pay for eligible employees.
* Career Pathways to Promote Professional Growth and Development
* Various Medical, Dental, and Vision options
* Tuition Reimbursement
* Free Parking at designated locations
* Wellness Program Savings Plan
* Health Savings Account Options
* Retirement Options with Company Match
* Paid Time Off
* Community Involvement Opportunities
Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. For more information, visit you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.
Please explore our website ( ) to better understand how Endeavor Health delivers on its mission to "help everyone in our communities be their best".
Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.
Diversity, equity and inclusion is at the core of who we are; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.
EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disabil
$40.45 - $62.70 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.
Position Highlights:
* Position: RN Patient Care Navigator
* Location: Skokie, IL
* Full Time: 40 hours
* Hours: Monday-Friday, 8:00a-4:30p rotating every 3rd weekend
* I winter holiday (Thanksgiving, Christmas, New Year) and 1 summer (Labor Day, July 4th, Memorial Day) coverage
* Required Travel: Highland Park, Glenbrook, Evanston, Swedish based on clinical needs, less than 1%
A Brief Overview:
The RN Transitional Care Navigator (Population Health) is responsible for the case management, care coordination management, and utilization management of his/her population of patients across multiple care levels and settings. Serves as a catalyst to promote patients understanding their diagnosis, treatment options, and available resources and ensure that they are connected with the optimal resources across the continuum of care. This role will coordinate and facilitate smooth and safe care transitions while ensuring quality cost-effective patient outcomes. Serves as a liaison between their patient population and all other providers. Will be responsible for key metrics of success, which include improving the overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30-day readmission rate and ED utilization.
What you will do:
* Guides high-risk patient and family through the health system from diagnosis, testing, treatment and follow-up care to assist patients with navigating the continuum of care. Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
* Establishes and documents an individualized plan of care for assigned patients using evidence-based treatment guidelines considering the patients individual health goals with a focus on wellness, health management, disease prevention and chronic disease management.
* Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
* Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
* Acts as advisor/educator by partnering with social work in providing emotional support including goals of care and counseling. Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision-making.
* Facilitates appointments for appropriate consultations and support services within established protocols
* Completes Utilization Management for assigned patients.
* Applies Milliman Care Guidelines (Indicia) criteria to monitor appropriateness of admissions and continued stays and documents findings based on Department standards.
* Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
* May need to travel to visit the patient at home from time to time.
* Available to his/her assigned patient population and participates as part of a call coverage structure.
* Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.
*
What you will need:
* Bachelors Degree Health Administration Required Or
* Bachelors Degree Nursing Required
* 3 Years Utilization review, discharge planning, case management or disease management preferred. Nursing experience in home services, ambulatory services working with high-risk patients beneficial.
* 2 Years Clinical nursing experience preferred.
* Adheres to and practices in alignment with contemporary standards of care as established by leading professional organizations, including but not limited to the American Academy of Ambulatory Care Nursing (AAACN), the American Case Management Association (ACMA), and the Case Management Society of America (CMSA).
* Interacts with and contributes to professional development of peers and other health care providers as colleagues. Shares knowledge and provides feedback with peers to contribute to an environment supportive of clinical education.
* Knowledge of InterQual or MCG criteria preferred.
* Clinical certification, such as case management certification, is beneficial.
* Able to communicate and work collaboratively with a range of stakeholders and team members.
* Knowledge of community resources.
* Experience with Microsoft Office Suite.
* Strong interpersonal and oral communication skills.
* Strong computer and data entry skills.
* Experience with Electronic Medical Record (EMR) platform preferred.
* Proven leadership skills.
* Ability to work independently, setting priorities to coordinate care plan efficiently.
* Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Required And
* Certified Case Manager (CCM?) - Commission for Case Manager Certification (CCMC) Preferred Or
* Ambulatory Care Nursing (RN-BC) - American Nurses Credentialing Center (ANCC) Preferred And
* BLS - Basic Life Support (CPR and AED) - American Heart Association (AHA) Required
Benefits (for full and part time positions):
* Premium pay for eligible employees.
* Career Pathways to Promote Professional Growth and Development
* Various Medical, Dental, and Vision options
* Tuition Reimbursement
* Free Parking at designated locations
* Wellness Program Savings Plan
* Health Savings Account Options
* Retirement Options with Company Match
* Paid Time Off
* Community Involvement Opportunities
Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. For more information, visit you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.
Please explore our website ( ) to better understand how Endeavor Health delivers on its mission to "help everyone in our communities be their best".
Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.
Diversity, equity and inclusion is at the core of who we are; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.
EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disabil
Not Specified
RN Patient Care Navigator- Oncology
✦ New 🏢 Endeavor Health
Salary not disclosed
Hourly Pay Range:
$40.45 - $62.70 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.
Position Highlights:
- Sign on bonus: (if applicable)
- Position:
- Location: [City, IL]
- Full Time/Part Time: [Full Time / Part Time]
- Hours: Monday-Friday, [hours and flexible work schedules]
- Required Travel:
A Brief Overview:
The RN Transitional Care Navigator (Population Health) is responsible for the case management, care coordination management, and utilization management of his/her population of patients across multiple care levels and settings. Serves as a catalyst to promote patients understanding their diagnosis, treatment options, and available resources and ensure that they are connected with the optimal resources across the continuum of care. This role will coordinate and facilitate smooth and safe care transitions while ensuring quality cost-effective patient outcomes. Serves as a liaison between their patient population and all other providers. Will be responsible for key metrics of success, which include improving the overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30-day readmission rate and ED utilization.
What you will do:
- Guides high-risk patient and family through the health system from diagnosis, testing, treatment and follow-up care to assist patients with navigating the continuum of care. Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
- Establishes and documents an individualized plan of care for assigned patients using evidence-based treatment guidelines considering the patients individual health goals with a focus on wellness, health management, disease prevention and chronic disease management.
- Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
- Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
- Acts as advisor/educator by partnering with social work in providing emotional support including goals of care and counseling. Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision-making.
- Facilitates appointments for appropriate consultations and support services within established protocols
- Completes Utilization Management for assigned patients.
- Applies Milliman Care Guidelines (Indicia) criteria to monitor appropriateness of admissions and continued stays and documents findings based on Department standards.
- Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
- May need to travel to visit the patient at home from time to time.
- Available to his/her assigned patient population and participates as part of a call coverage structure.
- Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.
What you will need:
- Bachelors Degree Health Administration Required Or
- Bachelors Degree Nursing Required
- 3 Years Utilization review, discharge planning, case management or disease management preferred. Nursing experience in home services, ambulatory services working with high-risk patients beneficial.
- 2 Years Clinical nursing experience preferred.
- Adheres to and practices in alignment with contemporary standards of care as established by leading professional organizations, including but not limited to the American Academy of Ambulatory Care Nursing (AAACN), the American Case Management Association (ACMA), and the Case Management Society of America (CMSA).
- Interacts with and contributes to professional development of peers and other health care providers as colleagues. Shares knowledge and provides feedback with peers to contribute to an environment supportive of clinical education.
- Knowledge of InterQual or MCG criteria preferred.
- Clinical certification, such as case management certification, is beneficial.
- Able to communicate and work collaboratively with a range of stakeholders and team members.
- Knowledge of community resources.
- Experience with Microsoft Office Suite.
- Strong interpersonal and oral communication skills.
- Strong computer and data entry skills.
- Experience with Electronic Medical Record (EMR) platform preferred.
- Proven leadership skills.
- Ability to work independently, setting priorities to coordinate care plan efficiently.
- Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Required And
- Certified Case Manager (CCM?) - Commission for Case Manager Certification (CCMC) Preferred Or
- Ambulatory Care Nursing (RN-BC) - American Nurses Credentialing Center (ANCC) Preferred And
- BLS ? Basic Life Support (CPR and AED) - American Heart Association (AHA) Required
Benefits:
- Career Pathways to Promote Professional Growth and Development
- Various Medical, Dental, and Vision options
- Tuition Reimbursement
- Free Parking at designated locations
- Wellness Program Savings Plan
- Health Savings Account Options
- Retirement Options with Company Match
- Paid Time Off
- Community Involvement Opportunities
$40.45 - $62.70 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.
Position Highlights:
- Sign on bonus: (if applicable)
- Position:
- Location: [City, IL]
- Full Time/Part Time: [Full Time / Part Time]
- Hours: Monday-Friday, [hours and flexible work schedules]
- Required Travel:
A Brief Overview:
The RN Transitional Care Navigator (Population Health) is responsible for the case management, care coordination management, and utilization management of his/her population of patients across multiple care levels and settings. Serves as a catalyst to promote patients understanding their diagnosis, treatment options, and available resources and ensure that they are connected with the optimal resources across the continuum of care. This role will coordinate and facilitate smooth and safe care transitions while ensuring quality cost-effective patient outcomes. Serves as a liaison between their patient population and all other providers. Will be responsible for key metrics of success, which include improving the overall cost of care, length of stay optimization, reduction in excess days, reduction in SNF utilization and improvement in SNF care transitions, reduction in 30-day readmission rate and ED utilization.
What you will do:
- Guides high-risk patient and family through the health system from diagnosis, testing, treatment and follow-up care to assist patients with navigating the continuum of care. Eliminates barriers to patient's access to health care services and facilitates continuity of care/care coordination.
- Establishes and documents an individualized plan of care for assigned patients using evidence-based treatment guidelines considering the patients individual health goals with a focus on wellness, health management, disease prevention and chronic disease management.
- Partners with the healthcare team to ensure clinical decision-making, implementation of recommendations, and discharge planning are timely and appropriate.
- Performs daily coordination between multiple departments, multi-disciplinary team, medical clinics, and community outreach to gain knowledge of patient, assure patient safety, smooth transitions of care, and manage utilization and total cost of care.
- Acts as advisor/educator by partnering with social work in providing emotional support including goals of care and counseling. Provides and/or arranges clinical education including medication management, community resources, financial resources, and expert guidance to patients and families to promote their ability to understand and meaningfully participate in the healthcare process and personal decision-making.
- Facilitates appointments for appropriate consultations and support services within established protocols
- Completes Utilization Management for assigned patients.
- Applies Milliman Care Guidelines (Indicia) criteria to monitor appropriateness of admissions and continued stays and documents findings based on Department standards.
- Monitors LOS and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
- May need to travel to visit the patient at home from time to time.
- Available to his/her assigned patient population and participates as part of a call coverage structure.
- Participates in the collection and analysis of data to identify under/over utilization; improve resource consumption; promote potential reduction in cost; and enhance quality of care consistent with organization strategic goals and objectives.
What you will need:
- Bachelors Degree Health Administration Required Or
- Bachelors Degree Nursing Required
- 3 Years Utilization review, discharge planning, case management or disease management preferred. Nursing experience in home services, ambulatory services working with high-risk patients beneficial.
- 2 Years Clinical nursing experience preferred.
- Adheres to and practices in alignment with contemporary standards of care as established by leading professional organizations, including but not limited to the American Academy of Ambulatory Care Nursing (AAACN), the American Case Management Association (ACMA), and the Case Management Society of America (CMSA).
- Interacts with and contributes to professional development of peers and other health care providers as colleagues. Shares knowledge and provides feedback with peers to contribute to an environment supportive of clinical education.
- Knowledge of InterQual or MCG criteria preferred.
- Clinical certification, such as case management certification, is beneficial.
- Able to communicate and work collaboratively with a range of stakeholders and team members.
- Knowledge of community resources.
- Experience with Microsoft Office Suite.
- Strong interpersonal and oral communication skills.
- Strong computer and data entry skills.
- Experience with Electronic Medical Record (EMR) platform preferred.
- Proven leadership skills.
- Ability to work independently, setting priorities to coordinate care plan efficiently.
- Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Required And
- Certified Case Manager (CCM?) - Commission for Case Manager Certification (CCMC) Preferred Or
- Ambulatory Care Nursing (RN-BC) - American Nurses Credentialing Center (ANCC) Preferred And
- BLS ? Basic Life Support (CPR and AED) - American Heart Association (AHA) Required
Benefits:
- Career Pathways to Promote Professional Growth and Development
- Various Medical, Dental, and Vision options
- Tuition Reimbursement
- Free Parking at designated locations
- Wellness Program Savings Plan
- Health Savings Account Options
- Retirement Options with Company Match
- Paid Time Off
- Community Involvement Opportunities
Not Specified
AVP Care Coordination
✦ New
Salary not disclosed
Job Description & Requirements
AVP Care Coordination
StartDate: ASAP Pay Rate: $2 $220000.00
Nuvance Health, now a part of Northwell Health, an award-winning non-profit health system, is seeking their next AVP of Care Coordination in Danbury, Connecticut!
The Position
- The AVP of Care Coordination will spearhead the strategic direction, management, continuous improvement, and overall day-to-day operations of the newly created centralized Denial Prevention Unit/Utilization Management team with dotted line reporting for local and entity-specific Case Management and Social Work departments.
- The AVP will strive to optimize patient outcomes, provided services, care plan development, complaint management, and length of stay metrics while guaranteeing alignment with best practices, hospital and system priorities, and regulatory requirements.
- Seeking a collaborative leader to energize teams and drive key initiatives around department structure, succession planning, and staffing throughout the organization.
- The AVP must be a passionate leader who will bring a level of urgency while upholding a high level of communication and collaboration with staff, physicians, and executive leadership to ensure delivery of evidence-based care.
- Ideal candidates will bring expertise in accreditation and regulatory guidelines, particulary the Medicare 2MN rule, Milliman and Interqual guidelines, to guarantee expectations are consistently met as well as relevant and demonstrable experience in collecting, analyzing, and aggregation of data to ensure that necessary action plans are being put into place.
- The ideal candidate will be a collaborative and highly visible leader with experience and desire to implement the best practices throughout Care Coordination while reporting to the Chief Revenue Officer.
- Preferred candidates will possess a robust background in Utilization Management, Physician Advisors, and Case Management and is able to demonstrate strategic thinking abilities backed by tangible evidence.
Requirements
- Bachelor's degree is required; a master's degree in nursing, health administration, and/or related field is strongly preferred.
- Active CT or NYS RN license is required.
- A minimum of five years of clinical experience within an acute care setting is required.
- A minimum of five years of progressive leadership experience in case management and/or utilization review is required.
Compensation Details
- The base salary range for this position is $200,000 to $220,000 annually. In addition, a leader may be eligible for other benefits, including but not limited to health insurance coverage, retirement benefits, and bonuses. The total compensation for the finalist selected for this role will be determined based on various factors, including but not limited to scope of role, level of experience, education, accomplishments, internal equity, budget, and subject to Fair Market Value evaluation. The base salary range listed above is a good faith determination of potential base compensation at the time of this job advertisement and may be modified in the future.
The Organization
- Nuvance Health, (Nuvance), an innovative, award-winning, non-profit health system, was formed in April 2019 through the merger of two leading health systems, Health Quest and Western Connecticut Health Network. "Nuvance", derived from a combination of the words "new" and "advance," reflects a mission to "continually progress and pursue impossible to enhance the health and well-bring of every person in the communities served."
- The newly created health system was developed to provide communities across New York's Hudson Valley and western Connecticut with more convenient, accessible, and affordable care. Nuvance Health is governed by a 17-member Board of Trustees. With seven hospitals, more than 2,600 aligned physicians, and 11,000 employees, Nuvance Health serves more than 1.5 million residents across western Connecticut and the Hudson River Valley.
- This region benefits from a strong economic base and a stable to growing population. The system's flagship hospitals, Danbury Hospital and Vassar Brothers Medical Center, each benefit from geographic positioning with minimal significant hospital-based service competition, while Norwalk Hospital operates within a highly competitive Fairfield County market. For FY 2021, Nuvance Health generated a breakeven operating margin on revenues of approximately $2.5M, and the system's balance sheet is solid. Leadership is focused on the continuing advancement of system integration to realize benefits of synergy and scale.
The Community
- Danbury, located in Fairfield County, Connecticut, is a vibrant city known for it's history, thriving economy, and proximity to both natural beauty and urban amenities.
- Danbury offers variety of attractions including the Danbury Railway Museum, Tarrywile Park & Mansion, Danbury Fair Mall, and the Danbury Ice Museum.
- Served by a well-regarded public school system, Danbury offers a multitude of educational opportunities including Danbury Public Schools, Western Connecticut State University, and Sacred Heart University. In addition, Danbury is also home to multiple private and charter schools including St. Gregory the Great School.
- Danbury offers a wide variety of family activities including Danbury Library, Danbury Farmer's Market, The Danbury Music Centre, and many annual cultural, music, and food festivals.
Please apply directly and for any further inquiries or referrals, direct them to:
Christine Young
Executive Recruiter
913-752-4532
#BESrecruitment
#LI-CY1
Job Benefits
About the Company
At AMN Healthcare, we strive to be recognized as the most trusted, innovative, and influential force in helping healthcare organizations provide quality patient care that continually evolves to make healthcare more human, more effective, and more achievable.
Care Coordination, Case Management, Case Manager, Care Manger, Utilization Manager, Utilization Management, Nursing Resource Management, Utilization Review, Nurse Navigator, Outpatient Case Management, Care Coordinator
AVP Care Coordination
StartDate: ASAP Pay Rate: $2 $220000.00
Nuvance Health, now a part of Northwell Health, an award-winning non-profit health system, is seeking their next AVP of Care Coordination in Danbury, Connecticut!
The Position
- The AVP of Care Coordination will spearhead the strategic direction, management, continuous improvement, and overall day-to-day operations of the newly created centralized Denial Prevention Unit/Utilization Management team with dotted line reporting for local and entity-specific Case Management and Social Work departments.
- The AVP will strive to optimize patient outcomes, provided services, care plan development, complaint management, and length of stay metrics while guaranteeing alignment with best practices, hospital and system priorities, and regulatory requirements.
- Seeking a collaborative leader to energize teams and drive key initiatives around department structure, succession planning, and staffing throughout the organization.
- The AVP must be a passionate leader who will bring a level of urgency while upholding a high level of communication and collaboration with staff, physicians, and executive leadership to ensure delivery of evidence-based care.
- Ideal candidates will bring expertise in accreditation and regulatory guidelines, particulary the Medicare 2MN rule, Milliman and Interqual guidelines, to guarantee expectations are consistently met as well as relevant and demonstrable experience in collecting, analyzing, and aggregation of data to ensure that necessary action plans are being put into place.
- The ideal candidate will be a collaborative and highly visible leader with experience and desire to implement the best practices throughout Care Coordination while reporting to the Chief Revenue Officer.
- Preferred candidates will possess a robust background in Utilization Management, Physician Advisors, and Case Management and is able to demonstrate strategic thinking abilities backed by tangible evidence.
Requirements
- Bachelor's degree is required; a master's degree in nursing, health administration, and/or related field is strongly preferred.
- Active CT or NYS RN license is required.
- A minimum of five years of clinical experience within an acute care setting is required.
- A minimum of five years of progressive leadership experience in case management and/or utilization review is required.
Compensation Details
- The base salary range for this position is $200,000 to $220,000 annually. In addition, a leader may be eligible for other benefits, including but not limited to health insurance coverage, retirement benefits, and bonuses. The total compensation for the finalist selected for this role will be determined based on various factors, including but not limited to scope of role, level of experience, education, accomplishments, internal equity, budget, and subject to Fair Market Value evaluation. The base salary range listed above is a good faith determination of potential base compensation at the time of this job advertisement and may be modified in the future.
The Organization
- Nuvance Health, (Nuvance), an innovative, award-winning, non-profit health system, was formed in April 2019 through the merger of two leading health systems, Health Quest and Western Connecticut Health Network. "Nuvance", derived from a combination of the words "new" and "advance," reflects a mission to "continually progress and pursue impossible to enhance the health and well-bring of every person in the communities served."
- The newly created health system was developed to provide communities across New York's Hudson Valley and western Connecticut with more convenient, accessible, and affordable care. Nuvance Health is governed by a 17-member Board of Trustees. With seven hospitals, more than 2,600 aligned physicians, and 11,000 employees, Nuvance Health serves more than 1.5 million residents across western Connecticut and the Hudson River Valley.
- This region benefits from a strong economic base and a stable to growing population. The system's flagship hospitals, Danbury Hospital and Vassar Brothers Medical Center, each benefit from geographic positioning with minimal significant hospital-based service competition, while Norwalk Hospital operates within a highly competitive Fairfield County market. For FY 2021, Nuvance Health generated a breakeven operating margin on revenues of approximately $2.5M, and the system's balance sheet is solid. Leadership is focused on the continuing advancement of system integration to realize benefits of synergy and scale.
The Community
- Danbury, located in Fairfield County, Connecticut, is a vibrant city known for it's history, thriving economy, and proximity to both natural beauty and urban amenities.
- Danbury offers variety of attractions including the Danbury Railway Museum, Tarrywile Park & Mansion, Danbury Fair Mall, and the Danbury Ice Museum.
- Served by a well-regarded public school system, Danbury offers a multitude of educational opportunities including Danbury Public Schools, Western Connecticut State University, and Sacred Heart University. In addition, Danbury is also home to multiple private and charter schools including St. Gregory the Great School.
- Danbury offers a wide variety of family activities including Danbury Library, Danbury Farmer's Market, The Danbury Music Centre, and many annual cultural, music, and food festivals.
Please apply directly and for any further inquiries or referrals, direct them to:
Christine Young
Executive Recruiter
913-752-4532
#BESrecruitment
#LI-CY1
Job Benefits
About the Company
At AMN Healthcare, we strive to be recognized as the most trusted, innovative, and influential force in helping healthcare organizations provide quality patient care that continually evolves to make healthcare more human, more effective, and more achievable.
Care Coordination, Case Management, Case Manager, Care Manger, Utilization Manager, Utilization Management, Nursing Resource Management, Utilization Review, Nurse Navigator, Outpatient Case Management, Care Coordinator
Not Specified
I
Utilization Review Nurse
🏢 IntePros
Salary not disclosed
Position Title: Utilization Review Nurse
Location: Fully Remote
Position Summary
The Utilization Review Nurse serves as a key liaison in coordinating resources and services to meet patients’ needs, ensuring efficient, cost-effective, and compliant delivery of home health care. This role monitors admissions, reauthorizations, extended certification periods, and ongoing care to ensure adherence to Medicare and regulatory guidelines while promoting positive patient outcomes.
Essential Responsibilities
- Review and process prior authorizations and reauthorization requests in accordance with company policy.
- Assess medical documentation to determine the need for continued home health services based on Medicare guidelines.
- Refer cases outside of established guidelines to the Utilization Review Physician Advisor.
- Maintain accurate and timely records of authorizations, communications, and payer interactions.
- Collaborate with provider staff to identify patient needs, coordinate care, and ensure appropriate resource utilization.
- Monitor patient progress and outcomes to support efficient, cost-effective care.
- Serve as a communication link and provide customer service support to payer case managers, patients, and provider teams.
- Submit required status and summary reports within deadlines.
- Participate in weekend and holiday rotation; remain available for after-hours support as needed.
- Review clinical documentation for compliance with CMS Chapter 7 and Milliman Care Guidelines; provide feedback to clinicians on medical necessity, homebound status, visit utilization, and discharge planning.
- Identify and escalate quality-of-care concerns to the Quality Assurance Committee/QPUC.
- Support the Utilization Review Committee/QPUC in addressing and resolving utilization-related issues.
Qualifications
- Graduate of an accredited program in professional, practical, or vocational nursing.
- Current, active nursing license (RN, LPN, or LVN), Compact
- Minimum of two (2) years of general nursing experience in medical, surgical, or critical care.
- At least one (3) years of experience in utilization review/management, case management, or recent home health fieldwork.
- Excellent oral and written communication abilities.
- Proven time management skills and ability to meet deadlines.
- Self-directed, flexible, and able to work independently with minimal supervision.
- Working knowledge of home care regulations and federal requirements.
Experience
- Familiarity with home health and community-based services.
- Experience in utilization or case management preferred.
- Knowledge of homecare, managed care, medical/nursing procedures, and community resources.
- NCQA and URAC experience is a plus.
- Proficiency with MS Office (Outlook, Word, Excel), Adobe, and multiple electronic medical record systems.
Not Specified
A
RN Clinical Review Nurse {167271}
Salary not disclosed
Clinical Review Nurse Schedule for Clinical Review Nurse Monday – Friday | 8:00 AM – 5:00 PM Interview Process for Clinical Review Nurse One virtual interview Job Overview for Clinical Review Nurse We are seeking an experienced Clinical Review Nurse to support the investigation and resolution of complex member and provider grievances, appeals, and disputes .
This role is responsible for conducting detailed clinical reviews, evaluating medical necessity, and ensuring compliance with applicable regulatory requirements and organizational policies.
The Clinical Review Nurse will collaborate with internal teams and medical leadership to ensure timely and accurate resolution of cases while maintaining high standards of care and service.
Key Responsibilities for Clinical Review Nurse Conduct investigations and clinical reviews of member and provider grievances and appeals related to medical necessity .
Review prospective, inpatient, and retrospective medical records associated with denied services.
Summarize and present medical findings for Medical Directors, consultants, and external reviewers .
Apply clinical guidelines, policies, and benefit plan documentation when evaluating cases.
Prepare recommendations to uphold or overturn determinations and submit to the Medical Director for final approval.
Ensure appeals, grievances, and disputes are resolved within required regulatory timelines .
Evaluate requests for expedited review and determine urgency criteria.
Document case details and maintain accurate records within relevant tracking systems.
Draft written correspondence for members, providers, and regulatory entities .
Communicate with members, providers, and internal staff to support resolution of clinical concerns.
Identify potential quality-of-care concerns and escalate appropriately.
Serve as a clinical resource and subject matter expert to assist team members with appeals and grievance resolution.
Participate in additional projects and duties as assigned.
Essential Functions for Clinical Review Nurse Conduct thorough investigations of appeals, grievances, and provider disputes .
Evaluate the appropriateness of care within contractual, regulatory, and accreditation standards.
Identify system or process issues that may impact member care or service expectations and recommend improvements.
Perform documentation, reporting, and analytical tasks related to case reviews.
Maintain compliance with organizational policies, regulatory requirements, and professional standards .
Minimum Qualifications for Clinical Review Nurse Education / Licensing Active and unrestricted California Registered Nurse (RN) license Bachelor’s degree preferred Experience for Clinical Review Nurse Minimum 3 years of acute care clinical experience Minimum 2 years of appeals and grievances casework Preferred Experience for Clinical Review Nurse Utilization Management or Quality Management Experience applying standardized clinical guidelines Familiarity with Milliman Care Guidelines (MCG) , Managed Care, and NCQA standards Additional Details for Clinical Review Nurse No direct supervisory responsibilities Collaborative role working with clinical, operational, and leadership teams If you are an experienced nurse with strong clinical review and case evaluation skills and are looking to contribute to a team focused on quality care and regulatory excellence, we encourage you to apply.
*
This role is responsible for conducting detailed clinical reviews, evaluating medical necessity, and ensuring compliance with applicable regulatory requirements and organizational policies.
The Clinical Review Nurse will collaborate with internal teams and medical leadership to ensure timely and accurate resolution of cases while maintaining high standards of care and service.
Key Responsibilities for Clinical Review Nurse Conduct investigations and clinical reviews of member and provider grievances and appeals related to medical necessity .
Review prospective, inpatient, and retrospective medical records associated with denied services.
Summarize and present medical findings for Medical Directors, consultants, and external reviewers .
Apply clinical guidelines, policies, and benefit plan documentation when evaluating cases.
Prepare recommendations to uphold or overturn determinations and submit to the Medical Director for final approval.
Ensure appeals, grievances, and disputes are resolved within required regulatory timelines .
Evaluate requests for expedited review and determine urgency criteria.
Document case details and maintain accurate records within relevant tracking systems.
Draft written correspondence for members, providers, and regulatory entities .
Communicate with members, providers, and internal staff to support resolution of clinical concerns.
Identify potential quality-of-care concerns and escalate appropriately.
Serve as a clinical resource and subject matter expert to assist team members with appeals and grievance resolution.
Participate in additional projects and duties as assigned.
Essential Functions for Clinical Review Nurse Conduct thorough investigations of appeals, grievances, and provider disputes .
Evaluate the appropriateness of care within contractual, regulatory, and accreditation standards.
Identify system or process issues that may impact member care or service expectations and recommend improvements.
Perform documentation, reporting, and analytical tasks related to case reviews.
Maintain compliance with organizational policies, regulatory requirements, and professional standards .
Minimum Qualifications for Clinical Review Nurse Education / Licensing Active and unrestricted California Registered Nurse (RN) license Bachelor’s degree preferred Experience for Clinical Review Nurse Minimum 3 years of acute care clinical experience Minimum 2 years of appeals and grievances casework Preferred Experience for Clinical Review Nurse Utilization Management or Quality Management Experience applying standardized clinical guidelines Familiarity with Milliman Care Guidelines (MCG) , Managed Care, and NCQA standards Additional Details for Clinical Review Nurse No direct supervisory responsibilities Collaborative role working with clinical, operational, and leadership teams If you are an experienced nurse with strong clinical review and case evaluation skills and are looking to contribute to a team focused on quality care and regulatory excellence, we encourage you to apply.
*
Not Specified
jobs by
