Milliman Utilization Review Jobs in Usa
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JOB TITLE: Clinical Review RN (Medicaid Cost Outlier)
Nurse Background: 5+ years of acute care/medical surgical experience required. Interqual/MCG experience a plus.
GENERAL RESPONSIBILITIES: This individual will complete the full spectrum of activities related to Utilization or Quality reviews as assigned. They will utilize their knowledge and expertise of the review program to conduct clinical level review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process.
DUTIES:
1. Conduct utilization reviews up to and including the appeal level. This includes chart screen, complete electronic worksheets, enter required information and make level one denial decisions when necessary.
2. Conduct quality and clinical study data collection reviews. This includes chart review, complete detailed electronic data worksheets.
3. Act as a resource for the administrative staff in training, problem solving, and clarifying procedures. Will provide technical assistance and conduct/participate in staff huddles.
4. Participate in collaborative training specific to clinical study objectives.
5. Other activities as may be deemed necessary.
QUALIFICATIONS:
1. Licensed as a Registered Professional Nurse in New York State.
2. Knowledge and experience with electronic medical records including utilization, quality, and clinical charting.
3. Ability to oversee, problem solve and work collaboratively with peers, medical, analytical, and administrative support staff.
4. Excellent written and verbal skills.
5. Ability to work independently with little supervision.
6. Ability and desire to be flexible, innovative, and creative.
EDUCATION & EXPERIENCE:
1. Baccalaureate degree in Nursing or graduate of an approved Registered Professional Nurses training program and licensed to practice in the State of New York.
2. A minimum of five years experience in an acute care facility preferably in medical surgical AND 1-3 years experience in acute care utilization review, preferable.
LOCATION: Jericho, NY (onsite)
***there is a free shuttle from the Jericho LIRR station + parking onsite
SHIFTS: M-F, 40 hours or 4x10s (no weekends)
PAY: $50-55/hr
DURATION: long term open ended contract includes benefits, sick time, 401k, weekly pay
Do you have the career opportunities as an RN Case Manager Lead you want with your current employer? We have an exciting opportunity for you to join HCA Florida Osceola Hospital which is part of the nation's leading provider of healthcare services, HCA Healthcare.
BenefitsHCA Florida Osceola Hospital offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:
- Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
- Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
- Free counseling services and resources for emotional, physical and financial wellbeing
- 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
- Employee Stock Purchase Plan with 10% off HCA Healthcare stock
- Family support through fertility and family building benefits with Progyny and adoption assistance.
- Referral services for child, elder and pet care, home and auto repair, event planning and more
- Consumer discounts through Abenity and Consumer Discounts
- Retirement readiness, rollover assistance services and preferred banking partnerships
- Education assistance (tuition, student loan, certification support, dependent scholarships)
- Colleague recognition program
- Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
- Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.
Learn more about Employee Benefits
Note: Eligibility for benefits may vary by location.
Our teams are a committed, caring group of colleagues. Do you want to work as an RN Case Manager Lead where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise!
Job Summary and QualificationsThe primary purpose of the Lead Case Manager is to ensure that primary operations of the Case Management/Utilization Review Department function efficiently. This position maintains a caseload or equivalent assignment as volume dictates while providing a first line resource to Case Managers, Utilization Review, and Medical Social Workers. This position routinely dialogs with the Manager and/or Director to ensure seamless front line communication.
- Performs a comprehensive assessment of psychosocial and medical needs of assigned patients, in collaboration with the assigned Treatment Coordinator.
- Acts as coordinator of patient/family/caregiver education and monitors documentation of education by team members. Promotes participation of the patient/family/caregiver in team discussions related to plans, goals and status through Family Conferences and other interactions.
- Ensures implementation of an individual treatment plan that supports patient strengths, abilities, needs, and preferences. Directs activities of the Patient Care Conference. Coordinates team activities in the implementation of patient treatment plan and re-assesses treatment plan after a change in patient condition. Facilitates the involvement of the patient throughout the rehabilitation process.
- Documents findings of the Discharge Planning Evaluation (DPE) and psychosocial assessments. Communicates information of social, financial or discharge needs and preferences of the patient/family/caregiver. Uses financial information available in decision making about the provision of services for the patient.
- Ensures communication with external and internal sources. Interacts with patients, team members and other stakeholders.
- Provides thorough verbal and/or printed information to help patients/families/caregivers make informed decisions about post-acute care options, while addressing goals of care and treatment preferences. Provides printed tools explaining how to access additional details from website.
- Adheres to hospital policy when making post discharge referrals, documenting the process in the patient record. Provides Patient Choice letter and full list of post-acute providers in patient's designated area.
- Provides or makes appropriate referral for individual, family, group, or sexual counseling as needed. Makes appropriate peer support referrals within the community prior to discharge.
- Facilitates discharge and arrangement of follow-up services. Facilitates implementation of discharge/transition recommendations. Identifies and utilizes appropriate community resources to meet patient discharge and continuity of care needs.
- Participates in quality improvement activities. Assists in the collection and analysis of utilization data, identification of improvement areas, and improvement plan implementation.
- Assumes accountability for promoting consistent, positive patient interactions that advance the agenda of unparalleled patient service.
- Maintains a patient-first philosophy and engages in service recovery when necessary.
- Supports the development and implementation of strategies to elevate the patient experience.
- Performs other duties as assigned.
- Practices and adheres to the Code of Conduct and Mission and Value Statement.
Associate Degree in Nursing or RN Diploma Required
- Bachelor's Degree in Nursing Preferred
- 3 years experience Required Years of Experience
HCA Florida Osceola Hospital is a 404-bed tertiary care hospital. We are accredited by the Joint Commission and are a Level II Trauma Center. We are a teaching hospital in collaboration with UCF College of Medicine. Our hospital is conveniently and centrally located in the Heart of Kissimmee. We are only minutes from Orlando, St. Cloud, Celebration, and Poinciana. We are committed to enhancing the standard of healthcare by providing services including Emergency Care, Trauma Care, Pediatric ER, Heart & Vascular Institute, and Comprehensive Stroke Center. Other services include The Baby Suites Maternity Care, Neonatal Intensive Care Unit Level II, Women's Services, Behavioral Health, Orthopedics & Spine, and a Graduate Medical Education Program. We expand our care to the community with our freestanding Emergency Department at Hunter's Creek ER.
HCA Healthcare has been recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.
Bricks and mortar do not make a hospital. People do.- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder
If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our RN Case Manager Lead opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!
We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
Do you have the career opportunities as an RN Case Manager Lead you want with your current employer? We have an exciting opportunity for you to join HCA Florida Osceola Hospital which is part of the nation's leading provider of healthcare services, HCA Healthcare.
BenefitsHCA Florida Osceola Hospital offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:
- Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
- Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
- Free counseling services and resources for emotional, physical and financial wellbeing
- 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
- Employee Stock Purchase Plan with 10% off HCA Healthcare stock
- Family support through fertility and family building benefits with Progyny and adoption assistance.
- Referral services for child, elder and pet care, home and auto repair, event planning and more
- Consumer discounts through Abenity and Consumer Discounts
- Retirement readiness, rollover assistance services and preferred banking partnerships
- Education assistance (tuition, student loan, certification support, dependent scholarships)
- Colleague recognition program
- Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
- Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.
Learn more about Employee Benefits
Note: Eligibility for benefits may vary by location.
Our teams are a committed, caring group of colleagues. Do you want to work as an RN Case Manager Lead where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise!
Job Summary and QualificationsThe primary purpose of the Lead Case Manager is to ensure that primary operations of the Case Management/Utilization Review Department function efficiently. This position maintains a caseload or equivalent assignment as volume dictates while providing a first line resource to Case Managers, Utilization Review, and Medical Social Workers. This position routinely dialogs with the Manager and/or Director to ensure seamless front line communication.
- Performs a comprehensive assessment of psychosocial and medical needs of assigned patients, in collaboration with the assigned Treatment Coordinator.
- Acts as coordinator of patient/family/caregiver education and monitors documentation of education by team members. Promotes participation of the patient/family/caregiver in team discussions related to plans, goals and status through Family Conferences and other interactions.
- Ensures implementation of an individual treatment plan that supports patient strengths, abilities, needs, and preferences. Directs activities of the Patient Care Conference. Coordinates team activities in the implementation of patient treatment plan and re-assesses treatment plan after a change in patient condition. Facilitates the involvement of the patient throughout the rehabilitation process.
- Documents findings of the Discharge Planning Evaluation (DPE) and psychosocial assessments. Communicates information of social, financial or discharge needs and preferences of the patient/family/caregiver. Uses financial information available in decision making about the provision of services for the patient.
- Ensures communication with external and internal sources. Interacts with patients, team members and other stakeholders.
- Provides thorough verbal and/or printed information to help patients/families/caregivers make informed decisions about post-acute care options, while addressing goals of care and treatment preferences. Provides printed tools explaining how to access additional details from website.
- Adheres to hospital policy when making post discharge referrals, documenting the process in the patient record. Provides Patient Choice letter and full list of post-acute providers in patient's designated area.
- Provides or makes appropriate referral for individual, family, group, or sexual counseling as needed. Makes appropriate peer support referrals within the community prior to discharge.
- Facilitates discharge and arrangement of follow-up services. Facilitates implementation of discharge/transition recommendations. Identifies and utilizes appropriate community resources to meet patient discharge and continuity of care needs.
- Participates in quality improvement activities. Assists in the collection and analysis of utilization data, identification of improvement areas, and improvement plan implementation.
- Assumes accountability for promoting consistent, positive patient interactions that advance the agenda of unparalleled patient service.
- Maintains a patient-first philosophy and engages in service recovery when necessary.
- Supports the development and implementation of strategies to elevate the patient experience.
- Performs other duties as assigned.
- Practices and adheres to the Code of Conduct and Mission and Value Statement.
Associate Degree in Nursing or RN Diploma Required
- Bachelor's Degree in Nursing Preferred
- 3 years experience Required Years of Experience
HCA Florida Osceola Hospital is a 404-bed tertiary care hospital. We are accredited by the Joint Commission and are a Level II Trauma Center. We are a teaching hospital in collaboration with UCF College of Medicine. Our hospital is conveniently and centrally located in the Heart of Kissimmee. We are only minutes from Orlando, St. Cloud, Celebration, and Poinciana. We are committed to enhancing the standard of healthcare by providing services including Emergency Care, Trauma Care, Pediatric ER, Heart & Vascular Institute, and Comprehensive Stroke Center. Other services include The Baby Suites Maternity Care, Neonatal Intensive Care Unit Level II, Women's Services, Behavioral Health, Orthopedics & Spine, and a Graduate Medical Education Program. We expand our care to the community with our freestanding Emergency Department at Hunter's Creek ER.
HCA Healthcare has been recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.
Bricks and mortar do not make a hospital. People do.- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder
If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our RN Case Manager Lead opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!
We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
Do you have the career opportunities as an RN Case Manager Lead you want with your current employer? We have an exciting opportunity for you to join HCA Florida Osceola Hospital which is part of the nation's leading provider of healthcare services, HCA Healthcare.
BenefitsHCA Florida Osceola Hospital offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:
- Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
- Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
- Free counseling services and resources for emotional, physical and financial wellbeing
- 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)
- Employee Stock Purchase Plan with 10% off HCA Healthcare stock
- Family support through fertility and family building benefits with Progyny and adoption assistance.
- Referral services for child, elder and pet care, home and auto repair, event planning and more
- Consumer discounts through Abenity and Consumer Discounts
- Retirement readiness, rollover assistance services and preferred banking partnerships
- Education assistance (tuition, student loan, certification support, dependent scholarships)
- Colleague recognition program
- Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
- Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.
Learn more about Employee Benefits
Note: Eligibility for benefits may vary by location.
Our teams are a committed, caring group of colleagues. Do you want to work as an RN Case Manager Lead where your passion for creating positive patient interactions is valued? If you are dedicated to caring for the well-being of others, this could be your next opportunity. We want your knowledge and expertise!
Job Summary and QualificationsThe primary purpose of the Lead Case Manager is to ensure that primary operations of the Case Management/Utilization Review Department function efficiently. This position maintains a caseload or equivalent assignment as volume dictates while providing a first line resource to Case Managers, Utilization Review, and Medical Social Workers. This position routinely dialogs with the Manager and/or Director to ensure seamless front line communication.
- Performs a comprehensive assessment of psychosocial and medical needs of assigned patients, in collaboration with the assigned Treatment Coordinator.
- Acts as coordinator of patient/family/caregiver education and monitors documentation of education by team members. Promotes participation of the patient/family/caregiver in team discussions related to plans, goals and status through Family Conferences and other interactions.
- Ensures implementation of an individual treatment plan that supports patient strengths, abilities, needs, and preferences. Directs activities of the Patient Care Conference. Coordinates team activities in the implementation of patient treatment plan and re-assesses treatment plan after a change in patient condition. Facilitates the involvement of the patient throughout the rehabilitation process.
- Documents findings of the Discharge Planning Evaluation (DPE) and psychosocial assessments. Communicates information of social, financial or discharge needs and preferences of the patient/family/caregiver. Uses financial information available in decision making about the provision of services for the patient.
- Ensures communication with external and internal sources. Interacts with patients, team members and other stakeholders.
- Provides thorough verbal and/or printed information to help patients/families/caregivers make informed decisions about post-acute care options, while addressing goals of care and treatment preferences. Provides printed tools explaining how to access additional details from website.
- Adheres to hospital policy when making post discharge referrals, documenting the process in the patient record. Provides Patient Choice letter and full list of post-acute providers in patient's designated area.
- Provides or makes appropriate referral for individual, family, group, or sexual counseling as needed. Makes appropriate peer support referrals within the community prior to discharge.
- Facilitates discharge and arrangement of follow-up services. Facilitates implementation of discharge/transition recommendations. Identifies and utilizes appropriate community resources to meet patient discharge and continuity of care needs.
- Participates in quality improvement activities. Assists in the collection and analysis of utilization data, identification of improvement areas, and improvement plan implementation.
- Assumes accountability for promoting consistent, positive patient interactions that advance the agenda of unparalleled patient service.
- Maintains a patient-first philosophy and engages in service recovery when necessary.
- Supports the development and implementation of strategies to elevate the patient experience.
- Performs other duties as assigned.
- Practices and adheres to the Code of Conduct and Mission and Value Statement.
Associate Degree in Nursing or RN Diploma Required
- Bachelor's Degree in Nursing Preferred
- 3 years experience Required Years of Experience
HCA Florida Osceola Hospital is a 404-bed tertiary care hospital. We are accredited by the Joint Commission and are a Level II Trauma Center. We are a teaching hospital in collaboration with UCF College of Medicine. Our hospital is conveniently and centrally located in the Heart of Kissimmee. We are only minutes from Orlando, St. Cloud, Celebration, and Poinciana. We are committed to enhancing the standard of healthcare by providing services including Emergency Care, Trauma Care, Pediatric ER, Heart & Vascular Institute, and Comprehensive Stroke Center. Other services include The Baby Suites Maternity Care, Neonatal Intensive Care Unit Level II, Women's Services, Behavioral Health, Orthopedics & Spine, and a Graduate Medical Education Program. We expand our care to the community with our freestanding Emergency Department at Hunter's Creek ER.
HCA Healthcare has been recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.
Bricks and mortar do not make a hospital. People do.- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder
If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our RN Case Manager Lead opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!
We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
$5,000 sign on bonus for external candidates with 1 year of nursing experience
$2,500 relocation bonus for over 50 miles OR $5,000 for over 100 miles
Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of the Carle Foundation Hospital. Ensures patients receive proactive initial assessment of needs, ongoing evaluations, and initiation of discharge planning while facilitating a safe and timely transition from the acute care/hospital setting to an appropriate level of care outside the hospital. Utilizes the five components of case management: assessment, coordination, monitoring, implementation, and evaluation. Multidisciplinary Rounds are completed daily with the care team at the patient's bedside which assists the team for timely planning and collaboration.
Qualifications
Certifications: Accredited Case Manager (ACM) within 3 years - American Case Management Association (ACMA); Basic Life Support (BLS) within 30 days - American Heart Association (AHA); Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR), Education: College Diploma: Nursing, Work Experience:
Responsibilities
Act as a liaison working with patient/family and physician to determine next level of careConducts case review presentations to educate peers on unique or challenging cases and scope of practice issues.Coordinates the transition from inpatient care to post-hospital care, working with pre- and post- hospital providers to ensure responsive and appropriate care is provided post-discharge.Documents plan of care and utilization issues in appropriate locations, including but not limited to: case management/utilization review software and the multidisciplinary plan of care document on all assigned patients.Evaluates effectiveness of plan of care to ensure the progression toward desired patient outcomes.Initiates intervention, both pre-hospital, in-hospital, and post-hospital, for patients and families identified from a proactive initial admission assessment, as well as through referrals from members of the health care team.Initiates timely referrals to other health care team members (quality improvement, risk manager, social workers, physicians, Home Services, etc.)Performs nursing activities of assessment, coordination, planning, monitoring, implementation, and evaluation. Interacts with clients, caregivers and families to assess, plan care, arrange services, monitor, and provide support and education.Proactively investigates coverage for post-hospital needs and presents options to the patient/family and provider.Provides oversight of acute setting plan of care to ensure coordination and completion of services to meet post-hospitalization needs.Lead an interdisciplinary team to achieve organizational goals related to length of stay and readmissions.Track avoidable days on inpatient stays. Readmission assessment of inpatient stays. Assess patients for post discharge needs. Participate in daily white board rounds. Arrange DME, Home Care, Hospice, assisting with returns to ECFs, and Transportation Assist any patient/family care conferences. Participate in department work groups. HRHC: make follow up appointments with primary care provider before patient discharges, makes post discharge phone calls to ensure patient is doing well and has what they need for success. Obtain prior authorizations for swing bed patients, maintain the work ques, and address denials. RMH: make follow up appointments with primary care provider before patient discharges, makes post discharge phone calls to ensure patient is doing well and has what they need for success. Initial utilization review for emergency room patients being admitted.
About Us
Find it here.
Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.
Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We've grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We're developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world's first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nation's highest honor for nursing care.
We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. For more information: .
Compensation and Benefits
The compensation range for this position is $34.01per hour - $58.5per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate's experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit /benefits.
$5,000 sign on bonus for external candidates with 1 year of nursing experience
$2,500 relocation bonus for over 50 miles OR $5,000 for over 100 miles
Responsible for the oversight, coordination, and management of the functional and financial outcomes during acute illness requiring hospitalization for patients of the Carle Foundation Hospital. Ensures patients receive proactive initial assessment of needs, ongoing evaluations, and initiation of discharge planning while facilitating a safe and timely transition from the acute care/hospital setting to an appropriate level of care outside the hospital. Utilizes the five components of case management: assessment, coordination, monitoring, implementation, and evaluation. Multidisciplinary Rounds are completed daily with the care team at the patient's bedside which assists the team for timely planning and collaboration.
Qualifications
Certifications: Accredited Case Manager (ACM) within 3 years - American Case Management Association (ACMA); Basic Life Support (BLS) within 30 days - American Heart Association (AHA); Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR), Education: College Diploma: Nursing, Work Experience:
Responsibilities
Act as a liaison working with patient/family and physician to determine next level of careConducts case review presentations to educate peers on unique or challenging cases and scope of practice issues.Coordinates the transition from inpatient care to post-hospital care, working with pre- and post- hospital providers to ensure responsive and appropriate care is provided post-discharge.Documents plan of care and utilization issues in appropriate locations, including but not limited to: case management/utilization review software and the multidisciplinary plan of care document on all assigned patients.Evaluates effectiveness of plan of care to ensure the progression toward desired patient outcomes.Initiates intervention, both pre-hospital, in-hospital, and post-hospital, for patients and families identified from a proactive initial admission assessment, as well as through referrals from members of the health care team.Initiates timely referrals to other health care team members (quality improvement, risk manager, social workers, physicians, Home Services, etc.)Performs nursing activities of assessment, coordination, planning, monitoring, implementation, and evaluation. Interacts with clients, caregivers and families to assess, plan care, arrange services, monitor, and provide support and education.Proactively investigates coverage for post-hospital needs and presents options to the patient/family and provider.Provides oversight of acute setting plan of care to ensure coordination and completion of services to meet post-hospitalization needs.Lead an interdisciplinary team to achieve organizational goals related to length of stay and readmissions.Track avoidable days on inpatient stays. Readmission assessment of inpatient stays. Assess patients for post discharge needs. Participate in daily white board rounds. Arrange DME, Home Care, Hospice, assisting with returns to ECFs, and Transportation Assist any patient/family care conferences. Participate in department work groups. HRHC: make follow up appointments with primary care provider before patient discharges, makes post discharge phone calls to ensure patient is doing well and has what they need for success. Obtain prior authorizations for swing bed patients, maintain the work ques, and address denials. RMH: make follow up appointments with primary care provider before patient discharges, makes post discharge phone calls to ensure patient is doing well and has what they need for success. Initial utilization review for emergency room patients being admitted.
About Us
Find it here.
Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.
Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care.
We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information:
Compensation and Benefits
The compensation range for this position is $34.01per hour - $58.5per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit /benefits.
The Valley Health System has expanded into an integrated health network that serves more than two million people in Southern Nevada. Starting with Valley Hospital Medical Center in 1979, the Valley Health System has grown to include Centennial Hills Hospital Medical Center, Spring Valley Hospital Medical Center, Summerlin Hospital Medical Center,Henderson Hospital, Valley Health Specialty Hospital, and West Henderson Hospital.
Benefit Highlights:
- Comprehensive education and training center
- Competitive Compensation & Generous Paid Time Off
- Excellent Medical, Dental, Vision and Prescription Drug Plans
- 401(K) with company match and discounted stock plan
- Career opportunities within VHS and UHS Subsidies
- Challenging and rewarding work environment
Job Description:
To achieve quality healthcare outcomes by establishing a safe, individualized discharge and providing proficient timely utilization management services to ensure that maximum reimbursement is achieved for all patient visits. These goals can be achieved through proactive collaboration with the patient, family and healthcare team.
Qualifications
Education: Graduate of an accredited school of nursing.
Experience: A minimum three years experience in varied clinical settings. Two years experience in Utilization Review, Utilization Management or Case Management preferred. Applicant must have knowledge of social and physical factors that affect functional status at discharge, and knowledge of community resources to meet post discharge clinical and social needs.
Technical Skills:
Computer proficiency to include word processing, spreadsheet, and data collection/management computer programs.
License/Certification:
Has a current license to practice as a Registered Nurse in the State of Nevada.
Other:
Must be able to demonstrate the knowledge and skills necessary to provide care/service appropriate to the age of the patients served on the assigned unit/department.
EEO Statement
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
We believe that diversity and inclusion among our teammates is critical to our success.
Notice
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at:
Seeking a Medical Director of Utilization Management--Full Time: 40 hrs/wk--Mon-Fri 8A-5P--Serve as the clinical expert on physician practice patterns, over- and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding, and documentation requirements.--Work closely with medical staff leadership, all medical staff, and ancillary departments to optimize services and ensure appropriateness of patient care.--Collaborate with hospital leadership to develop care management protocols that drive improvements and effectively manage resources.--Guaranteed base salary--Health, life, and disability coverage--3 retirement savings plans ? 401a, 403b with match, 457b--Paid time off benefits--CME allowance, license, and DEA reimbursement--Customized wellbeing resources--Free fitness center membership--Paid Parental Leave--Paid malpractice with tail coverage--Required: Current CHCQM-PHYADV certification, or ability to obtain within 90 days of employment, Board Certification, Active, unrestricted NC medical license.--5+ years of post-residency clinical practice experience PLUS at least one year of prior UM experience.--Thorough understanding of current CMS and DNV compliance requirements--Robust knowledge of hospital coding and billing, payer contracting, and revenue cycle management.--Effective collaboration with physician peers, administration, and support staff.--Advanced proficiency with EMRs and utilization review tools.
Seeking a Medical Director of Utilization Management Full Time: 40 hrs/wk Mon-Fri 8A-5P Serve as the clinical expert on physician practice patterns, over- and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer regulations, appropriate physician coding, and documentation requirements.
Work closely with medical staff leadership, all medical staff, and ancillary departments to optimize services and ensure appropriateness of patient care.
Collaborate with hospital leadership to develop care management protocols that drive improvements and effectively manage resources.
Guaranteed base salary Health, life, and disability coverage 3 retirement savings plans 401a, 403b with match, 457b Paid time off benefits CME allowance, license, and DEA reimbursement Customized wellbeing resources Free fitness center membership Paid Parental Leave Paid malpractice with tail coverage Required: Current CHCQM-PHYADV certification, or ability to obtain within 90 days of employment, Board Certification, Active, unrestricted NC medical license.
5+ years of post-residency clinical practice experience PLUS at least one year of prior UM experience.
Thorough understanding of current CMS and DNV compliance requirements Robust knowledge of hospital coding and billing, payer contracting, and revenue cycle management.
Effective collaboration with physician peers, administration, and support staff.
Advanced proficiency with EMRs and utilization review tools.
- Position: RN Unit Manager
- Pay: $35.00-$45.00/hr (based on experience)
- Bonus: $10,000 Sign-On Bonus
- Schedule: Full-time leadership role
- Benefits: Medical, Dental, Vision, Life Insurance, 401(k) with company match
- Paid Time Off: Paid holidays and paid vacation
- Extras: Best-in-class employee referral program
At Huntsville Health and Rehabilitation, we’re more than a healthcare facility — we’re a community committed to helping residents regain strength, confidence, and independence. Our long-term care and rehabilitation environment allows leaders to build meaningful relationships with residents, families, and staff while delivering high-quality, person-centered care.
We are currently seeking a qualified and motivated RN Unit Manager to provide clinical leadership and oversight within our facility.
Position Overview: RN Unit ManagerThe RN Unit Manager is responsible for overseeing day-to-day nursing operations for their assigned unit. This role supervises and develops nursing staff, ensures regulatory compliance, and works closely with the Director of Nursing to maintain exceptional standards of resident care. The Unit Manager also serves as a dependable and personable liaison between residents, families, and the interdisciplinary care team.
Key Responsibilities:- Oversee daily resident care operations and ensure quality, safety, and compliance
- Supervise, direct, and develop nursing staff to support performance and professional growth
- Ensure unit compliance with federal and state regulations and facility policies and procedures
- Assist in maintaining resident care standards through oversight of quality assurance, infection control, and utilization review activities
- Receive and communicate physician orders related to resident care and ensure proper implementation
- Oversee delegation of nursing and therapeutic procedures to licensed and unlicensed staff
- Conduct regular resident rounds to assess physical conditions, behaviors, and quality of care
- Ensure accurate and timely documentation of treatments and nursing observations
- Serve as a professional and approachable liaison between residents, families, and staff
- Current and active Registered Nurse (RN) license in the state of employment
- Minimum of two (2) years of nursing experience
- At least one (1) year of supervisory or leadership experience
- Experience in long-term care, skilled nursing, or working with the geriatric population preferred
- Strong organizational, planning, and personnel management skills
- Ability to read reports, interpret data, and utilize information accurately
- Proven ability to plan, direct, and coordinate nursing services in collaboration with other departments
- Professional, dependable, and resident-focused leadership style
- Competitive wages
- $10,000 sign-on bonus
- Elite low-cost Gold Plan Blue Cross Blue Shield health insurance
- (low premiums and low deductibles)
- Dental insurance
- Vision insurance
- Life insurance
- 401(k) retirement plan with company match
- Paid holidays
- Paid vacation
- Best-in-class employee referral program
If you’re an experienced Registered Nurse (RN) with a passion for leadership and delivering exceptional resident care, we’d love to hear from you.
Apply today to join the Huntsville Health and Rehabilitation team as an RN Unit Manager.
EOE
