Milliman Utilization Review Jobs in Usa

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• 60% Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions thatconsist of: intensive assessment/evaluation of condition, at risk education based on members' identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement.
  
• 20% Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but isnot limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
  
• 10% Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Serves as member advocate through continued communication and education. Promotes enrollment in care management programs and/or health and disease management programs.
  
• 5% Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
  
• 5% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
  

Immediate need for a talented Registered Nuse – Case Manager. This is a 03 months contract opportunity with long-term potential and is located in San Jose,CA(Onsite). Please review the job description below and contact me ASAP if you are interested.

Job ID:26-04999

Pay Range: $75 - $90/hour. Traveler benefits as per agency package. (Benefits vary by vendor and assignment.)

Key Responsibilities:

• 5 days/week including every other weekend (Saturday & Sunday)
• Headcount: 2 Travelers
• Perform daily pre-admission, admission, and concurrent utilization reviews
• Determine appropriate levels of care using clinical guidelines and policies
• Coordinate inpatient discharge planning and transitions of care
• Participate in multidisciplinary rounds with physicians and care teams
• Communicate discharge plans with patients, families, and external providers
• Arrange transfers, post-acute services, and obtain authorizations as needed
• Ensure continuity of care through accurate documentation and follow-up
• Maintain compliance with federal, state, and institutional regulations
• Educate care teams on utilization and care coordination processes

Key Requirements and Technology Experience:

• Key Skills; Inpatient Case Management & Discharge Planning
• Utilization Management / Utilization Review (UM/UR)
• Acute hospital experience (inpatient setting)
• Knowledge of CMS, DMHC, NCQA, TJC, HIPAA, EMTALA
• Strong interdisciplinary communication and care coordination
• Ability to independently manage inpatient caseloads
• Healthcare benefit interpretation and authorization coordination
• Graduate of an accredited school of nursing
• Diploma or Associate Degree in Nursing (ADN) required
• Active California RN License (Required)
• BLS Certification (Required)
• Minimum 2 years of experience in:
• Utilization Management
• Case Management
• Discharge Planning
• Recent acute inpatient hospital experience
• Ability to work rotating schedules and every other weekend
• Comfortable working in a Labor/Management Partnership environment
• Bachelor’s degree in Nursing or healthcare-related field
• Master’s degree in Case Management

Our client is a leading IT Consulting Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

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Kirby Bates Associates has been exclusively retained by Aspirus Health to conduct a search for their next Director, System Care Coordination.

Aspirus Health is a non-profit, community-directed health system, with a network of 19 hospitals, clinics, post-acute care facilities, and a health plan dedicated to providing high-quality, compassionate care to patients across Wisconsin, Minnesota, and Michigan’s Upper Peninsula. The organization is committed to delivering innovative healthcare services, advancing patient safety, and promoting clinical excellence through its team of dedicated healthcare professionals.

Aspirus Health is seeking an experienced and strategic leader to oversee system-wide care coordination functions, including utilization review, social work, navigation, and case management. This critical role is responsible for executing Aspirus’ care coordination strategic plan, ensuring seamless transitions of care, and driving initiatives that enhance health system and health plan goals. The Director will lead the development and implementation of best practices, policies, and procedures across the continuum of care—spanning hospitals, clinics, post-acute settings, and contracted services—while supervising a multidisciplinary team of registered nurses, social workers, and other healthcare professionals.

As a key partner to system leadership, the Director will collaborate with business units to optimize resource utilization, improve patient outcomes, and achieve strategic objectives. This role demands expertise in quality improvement, care model redesign, and change management, as well as a strong ability to foster professional practice and team development. With accountability for financial stewardship, program development, and regulatory compliance, the Director will play a pivotal role in shaping the future of care coordination at Aspirus Health. This is an outstanding opportunity to lead innovative programs in a dynamic and collaborative healthcare environment.

Opportunity Highlights:

Strategic Leadership Across a Comprehensive Health System

Spearhead system-wide care coordination initiatives across the system encompassing hospitals, clinics, post-acute care, and contracted services and implement an integrated care management strategy that drives seamless transitions of care and supports organizational goals.

Innovative Approach to Education and Development

Develop and execute forward-thinking strategies that integrate evidence-based practices and advanced data analytics to enhance care delivery, optimize resource utilization, and improve patient outcomes.

Engaging, Growth-Oriented Culture

Join a dynamic and collaborative environment that values innovation, professional development, and measurable impact. Aspirus Health offers robust opportunities for leadership growth, career advancement, and the chance to shape the future of care coordination across an expansive health system.

Qualifications:

• Bachelor’s in nursing and Master’s in business, healthcare administration, or nursing required.
• Nationally recognized certification preferred, i.e. CPHQ, CCM, CPUM, CPUR, or D-ABQAURP.
• Five or more years of leadership experience in care coordination, case mangement, or utilization review in an integrated healthcare delivery system and/or health plan.
• Extensive knowledge of payer mechanisms, clinical utilization management, outcome measures and patient information systems in including Pathways, HEDIS, etc.

Medical Director - Utilization Review

The Physician leader is responsible for advancing the delivery of safe, high-quality, and cost-effective medical care across multiple health plan offerings. This role provides clinical leadership and expertise to support Utilization Management, Care Management, and related business functions where physician involvement is essential to achieving optimal outcomes.

Key Responsibilities

• Provide physician leadership and clinical guidance to Utilization Management and Care Management functions
• Render coverage and payment determinations in accordance with health plan benefits, medical policies, and provider contracts
• Apply evidence-based clinical guidelines and best practices to support consistent, high-quality decision-making
• Exercise informed medical judgment grounded in clinical medicine, patient safety, quality management, and population health principles
• Collaborate effectively with clinical teams, operational leaders, senior management, and external partners
• Promote efficient, cost-effective care delivery across all lines of business
• Support organizational initiatives related to quality improvement, compliance, and healthcare outcomes

Required Qualifications & Experience

• Medical Doctor (MD) or Doctor of Osteopathy (DO) from an accredited medical or osteopathic medical school recognized by AAMC, AOA, or WHO
• Unrestricted and active Pennsylvania medical or osteopathic license
• Current board certification through ABMS or AOBMS (Family Medicine or Internal Medicine preferred)
• Ability to successfully complete organizational credentialing requirements
• Strong knowledge of Utilization Management, healthcare delivery systems, and payer-based medical decision-making

Work Location

• Fully Remote: This position is designated as fully remote
• Candidate must reside within the Tri-State Area (Pennsylvania, New Jersey, or Delaware)

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.

HCA 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!

The 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.

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.

HCA 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!

The 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.

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.

HCA 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!

The 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.

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.

Tittle: Case Manager RN

Location: Tallahassee, FL

Shift: Evening shift

Duration: Full time / Permanent role

Sign on Bonus: $10,000

Relocation Assistance: Case by case basis

Shift Differentials: Evening Shift - $2.50 Weekend Shift - $2.00

Job Summary and Qualifications

The RN CM Care Coordinator will facilitate the interdisciplinary plan of care with a focus on evaluating the appropriateness of clinical care, medical necessity, admission status, level of care, and resource management. The RN CM Care Coordinator will coordinate activities that promote quality outcomes and patient throughput while supporting a balance of optimal care and appropriate resource utilization. The RN CM Care Coordinator will identify potential barriers to patient throughput and quality outcomes and will facilitate appropriate discharge plans.

ESSENTIAL FUNCTIONS:

• Performs a comprehensive assessment of psychosocial and medical needs of assigned patients
• Develops a case management plan of care to include identified clinical, psychosocial and discharge needs; coordinates plan of care; plan is documented in the medical record; plan is communicated to appropriate clinical disciplines
• Assumes a leadership role with the interdisciplinary team to manage care, through criteria driven processes, for the appropriate level of care, patient status and resource utilization
• Conducts interdisciplinary team meetings to provide a mechanism for all clinical disciplines to collaborate, plan, implement, and assess the plan of car; patient selection should be criteria based and interventions will be documented
• Evaluates admissions for medical necessity using approved criteria at defined intervals throughout the episode of care; escalates medical necessity and admission status issues through the established chain of command
• Evaluates and assess observation patients for appropriateness in observation status
• Performs utilization management reviews and communicates information to third party payors
• Acts as a liaison through effective and professional communications between and with physicians, patient / family, hospital staff, and outside agencies
• Demonstrates knowledge of regulatory requirements, facility ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives as it relates to the provision of Case Management Services
• Makes appropriate referrals to third party payer disease and case management programs for recurring patients and patients with chronic disease states
• Documents professional recommendations, care coordination interventions, and case management activities to effectively communicate to all members of the health care team
• Facilitates patient throughput with an ongoing focus on quality and efficiency
• Tracks and trends barriers to care; makes recommendations and develops action plans to improve processes and systems
• Involves patient, family/responsible/significant others in identifying and clarifying needs and expectations to develop mutual and realistic goals
• Assesses patients’ post discharge needs and facilitates the provision of services necessary to meet identified needs
• Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered
• Identifies patients with the potential for high risk complications and makes appropriate referrals acting as an advocate for the individual’s healthcare needs
• Directs activities to identify and provide for the needs of the under resourced patient population to include patient education activities, patient assistance programs, and community based resources
• Develops individual plans of care for recurring patients to include education on appropriately accessing healthcare resources, preventative education, and community based resources
• Assumes a leadership role in the development, revision, and implementation of clinical protocols which transition patients across the continuum of care or discharge patients to an appropriate service level of care
• Adheres to established policy and procedure and standards of care; escalates issues through the established Chain of Command timely
• Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered.

Qualifications:

• Candidates are required to have a minimum of 3 years of RECENT (Within the last year) Case Manager experience in an acute care setting.
• Also open to candidates with 3 years of experience on the following units: Med/Surg, Tele, Neuro, ICU, PCU, or ED. will also consider candidates with Case manager experience in home health or insurance. For home health and insurance, they must have 3 years of acute care experience total and must have at least 1 year of acute care experience within the last 5 years.
• Associate's degree in nursing or Diploma in Nursing required
• Bachelor’s degree in nursing preferred
• Current FL RN license required or appropriate compact licensure. If compact license held, active FL RN licenserequiredwithin90 days of hire
• Advanced Practice Registered Nurse license is acceptable for position if current and compliant
• Certification in Case Management, Nursing, or Utilization Review, preferred

• 
  
• 50% Performs medical or behavioral review/authorization process. Ensures coverage for appropriate services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.). Participates in data collection/input into system for clinical information flow and proper claims adjudication. Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
  
• 25% Provides discharge planning and assesses service needs in cooperation with providers and facilities. Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions. Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits. Collaborates with client's Care Management and other areas to ensure proper care management processes are executed within a timely manner. Manages assigned members and authorizations through appropriate communication.
  
• 15% Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.
  
• 5% Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans. May identify, initiate, and participate in on-site reviews. Promotes enrollment in care management programs and/or health and disease management programs. 5% Maintains current knowledge of contracts and network status of all service providers and applies appropriately. Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
  

Contract Details

• Care Manager RN
• Location: York, Maine
• Duration: 13 Weeks
• Schedule: 8am to 4:30pm or 4 10 hour shifts at 7:30am to 5pm
• Hours: 40 hours per week
• BLS, ACLS and CCM or ACM preferred
• 3 to 5 years of clinical experience in Med Surg, home care, hospital case management and or previous utilization review experience
• MUST have utilization and discharge planning experience
• Weekly Gross Pay: $2,394.80
  • Taxed weekly = $960.00
  • Untaxed weekly = $1434.80
• Benefits
  • Medical, dental and vision
  • Free primary care and mental health services via teladoc
  • PTO after 90 days
  • Referral bonus
  • W2 employer
  • Weekly pay

Job Description:

The Care Manager RN coordinates and manages patient care across the healthcare continuum to ensure high-quality, cost-effective outcomes. This role focuses on care planning, discharge coordination, utilization review, and collaboration with interdisciplinary teams to support patients in achieving optimal health and safe transitions of care.

Key Responsibilities

• Conduct comprehensive patient assessments (clinical, psychosocial, and discharge needs)

• Develop, implement, and update individualized care plans

• Coordinate care with physicians, nurses, therapists, social workers, and community resources

• Facilitate safe discharge planning and transitions to home, SNF, rehab, or other levels of care

• Perform utilization review to ensure appropriate level of care and length of stay

• Monitor patient progress and adjust plans as needed

• Educate patients and families regarding diagnoses, medications, and follow-up care

• Advocate for patients to ensure access to necessary services and resources

• Ensure compliance with regulatory, payer, and facility guidelines

• Document case management activities accurately and timely

#Talroovms

Were unique. You should be, too.

Were changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?

Were different than most primary care providers. Were rapidly expanding and we need great people to join our team.

The Case Manager is responsible for enhancing the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integrating and functions of case management, utilization review and discharge planning. The incumbent in this role adheres to strict departmental goals/objectives, standards of performance, regulatory compliance, quality patient care compliance and policies and procedures.

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Coordinates the integration of social services/case management functions into the patient care, discharge and home planning processes with other departments, external service organizations, agencies and healthcare facilities.
• Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff.
• Acts as a patient advocate: investigates and reports adverse occurrences and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
• Promotes effective and efficient utilization of clinical resources and mobilizes resources to assist in achieving desired clinical outcomes within specific timeframe.
• Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided.
• Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians in maintaining appropriate cost, case and desired patient outcomes.

Other responsibilities may include:

• Coordinates the provision of social services to patients, families and significant others to enable them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
• Completes expanded assessment of patients and family needs at time of admission. Completes psychosocial assessment.
• Refers cases where patients and/or family would benefit from counseling to complete complex discharge plan to social worker.
• Serves as a patient advocate. Enhances a collaborative relationship to maximize the patients and familys ability to make informed decisions.
• Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education and identified post-hospital needs.
• Directs and participates in the development and implementation of patient care policies and protocols to provide advice and guidance in handling special cases or patient needs.
• Performs other duties as assigned and modified at managers discretion.

KNOWLEDGE, SKILLS AND ABILITIES:

• Thorough knowledge of case management principles, healthcare management and reimbursement.
• Strong written and verbal communication skills; presentation skills.
• Ability to convey medical terms and treatment plans so they are understood by patients and their caregivers.
• Excellent organizational and time management skills.
• Astute problem-solving skills with the ability to multi-task.
• Compassionate and empathetic demeanor with the ability to work both independently and in a group/team environment.
• General computer knowledge and effective Microsoft Office Products (PowerPoint, Excel, Word and Outlook) skills, plus the ability to use a variety of other word-processing, spreadsheet, database, e-mail and presentation software.
• Ability and willingness to travel locally, regionally and/or nationwide up to 10% of the time.
• Spoken and written fluency in English.

PAY RANGE:

$35.8 - $51.17 Hourly

EMPLOYEE BENEFITS

Were ChenMed and were transforming healthcare for seniors and changing Americas healthcare for the better. Family-owned and physician-led, our unique approach allows us to improve the health and well-being of the populations we serve. Were growing rapidly as we seek to rescue more and more seniors from inadequate health care.

ChenMed is changing lives for the people we serve and the people we hire. With great compensation, comprehensive benefits, career development and advancement opportunities and so much more, our employees enjoy great work-life balance and opportunities to grow. Join our team who make a difference in peoples lives every single day.

Current Employee apply HERE

Current Contingent Worker please see job aid HERE to apply

#LI-Onsite

Required

Preferred

Job Industries

• Other

The Department of Medicine of the University Of Maryland School Of Medicine and the Marlene and Stewart Greenebaum Comprehensive Cancer Center (UMGCCC), located in Baltimore, MD are recruiting for a full-time Medical Director of the University of Maryland St. Joseph Cancer Institute, located in Towson, MD.

GENERAL SUMMARY

• In conjunction with the leadership team develops, evaluates and implements clinical programs that creates competitive and clinically appropriate patient access
• Represents oncology service line to the community, collaborating with a variety of stakeholders to ensure seamless access to services, robust patient education and innovative screening programs
• Acts as admitting, attending and/or consulting physician for patients who require hospitalization for primary medical diagnoses, depending on needs of patients, medical staff and hospital
• Ensure delivery of care and services meet regulatory, practice and accreditation standards
• Provide medical expertise in matters involving capital/strategic planning, space modifications, infection control, policies and procedures, safety, and emergency preparedness
• Identifies and promotes areas to improve patient safety, corrects inappropriate and or inadequate medical care and takes overall ownership to resolve conflicting patient care decision making
• In collaboration with Oncology Practice Leadership and UM SJMC Leadership teams, develop annual clinical operational goals and interventions in alignment with Oncology Clinical Service Line roadmap.
• Attend UM Cancer Network Clinical and Research group meetings and ensure material is matriculated to onsite teams for evaluation, development and implementation in accord with institutional research processes
• Conducts physician peer review activities as requested by medical staff office
• Assist in the development and training of formal continuing medical education of onsite providers
• Support marketing and program development outreach efforts and actively participates in community activities.
• Other UM Cancer Network Affiliation duties as assigned

ESSENTIAL FUNCTIONS

1. Provides leadership and oversight of the delivery of medical care by clinical staff through direct supervision and audits.
2. Promotes and models the characteristics of a highly reliable organization, expressing a preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience and deference to expertise.
3. Directs activities related to the delivery of medical care and clinical services such as cost management, utilization review, quality assurance, and medical protocol development.
4. Participates in the recruitment and selection process of medical providers and provides regular performance reviews and feedback. Assists in the development of standards and qualifications for providers.
5. Serves as a mentor by providing education and developmental opportunities to clinical staff.
6. Manages the resolution of practice related issues of provider staff.
7. Attends standing meetings (board, committee, etc.).
8. Monitors quality and appropriateness of medical care. Insures timely and accurate record keeping and documentation to support clinical and reimbursement activity.
9. Provides oversight of utilization and risk management activities including monitoring of service utilization, adherence to corporate compliance plan, attainment of productivity targets. etc.
10. Develops policies and procedures for clinical protocols. Manages strategic development for the practice.

Note: The intent of this list of primary duties is to provide a representative summary of the major duties and responsibilities of this job. Incumbents perform other related duties as assigned. Specific duties and responsibilities may vary based upon departmental needs.

SERVICE EXCELLENCE BEHAVIORS

• Models and integrates FPI’s service excellence values and behaviors in all operational functions to achieve and maintain a high-quality culture of service excellence in all areas for which he/she is accountable.
• Demonstrates ability to lead others to ensure that all service excellence goals and objectives are met at all levels within the department.

DIRECTOR COMPENTENCIES

Professional Knowledge/Expertise

• Advances job competence and expertise by advancing leadership, interpersonal, professional and technical competences as indicated in best practices.
• Participates actively in learning new activities and quickly applies acquired knowledge. Participates in professional activities that enhance skills, knowledge and abilities. Networks effectively and strives to achieve certifications and advances degrees where appropriate.
• Serves as a respected coach, teacher, and mentor by demonstrating 2-way communication an effective interpersonal skill. Coaches, teaches and mentors staff using approaches that are effective for adults learning. Displays high levels of emotional intelligence.
• Creates a motivational climate that values diversity and encourages shared learning; creates a climate that inspires employees to work at their highest potential. Values diversity and supports that lead to the well-being and satisfaction of employees. Is non-defensive, open to feed-back and receptive to learning new ideas.

Resource Management

• Actions support optimal use of resources and FPI property.
• Exercises sound financial judgment. Develops contingency plans to address evolving financial issues. quickly adapts to changing economic conditions by considering costs, benefits and overall value of work efforts. Manages within budget limits; effectively balances resources (i.e., human, technology and money.)
• Promotes cost containment, savings and/or revenue opportunities. Minimizes expenditures by seeking non-to-low-cost alternatives.
• Manages risk; protects financial resources by creating a safe and accident-free environment. Ensures responsible use of equipment and property; holds self and employees accountable for the responsible use of company-owned property and equipment.

Process Improvement and Capacity Building

• Be a champion of UMMS mission and shared values by embracing new ideas, principles, practices and tools that will, over time, reshape the care we deliver to patients and each other.
• Leads, facilitates, and participates in efforts that result in effective strategic planning and continuous quality improvement. Quickly adapts to change, effectively manages transitions and develops new solutions for addressing evolving challenges
• Creates strategic and operational business plans; utilizes contemporary principles of strategic planning. Develops meaningful outcomes and performance measures and monitor's progress. Align goals; Produce results.
• Engages staff in Continuous Quality Improvement (CQI) activities; identifies key processes to ensure that they meet customer requirements. Facilitates process improvement activities by effective using CQI processes and tools.
• Quickly adapts to change and manages effective transitions. Implements and sustains change efforts, manages transitions effectively and seeks new ways to meet evolving challenges.
• Promotes effective problem-solving efforts and encourages new ideas. Promotes efforts that successfully engage employees in effective problem-solving and decision-making practices. Lead others and hold self-accountable for generating new ideas that contribute to cost-savings, increase efficiency or improved effectiveness.

MINIMUM QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

• Doctoral degree in Medicine in area of specialty.
• 5+ years of clinical experience.
• 3-5 years of leadership experience.
• CPR required.
• ACLS/BCLS required.
• Board certification/eligibility in area of specialty
• Demonstrated ability to promote professionalism through involvement in professional organizations, teaching, research, and/or publishing.
• Ability to demonstrate knowledge and skills necessary to provide care appropriate to the patient population(s) served. Ability to demonstrate knowledge of the principles of growth and development over the life span and possesses the ability to assess data reflective of the patient’s requirements relative to his or her population-specific and age specific needs.
• Highly effective verbal and written communication skills to interact with patients, patient’s families, departmental units, and medical and nursing staff on all essential matters.

Hospital size: 80 beds

The Chief Medical Officer (CMO) is responsible for providing leadership, strategic direction and overall operational management of physician services and medical staff administration for the campus. The CMO works with the market CEO to develop strategic plans and policies and address operational issues to build effective relationships between the hospital and its medical staff. The CMO also drives excellence in clinical outcomes. Working with the campus Chief Nursing Officer (CNO) and campus Safety and High Reliability Leader, the CMO creates multidisciplinary approaches to clinical outcome management and environments of quality and safety. The CMO partners with AdventHealth medical staff and system leadership on system-wide standardizations. Works to educate, consult and advise members of the medical staff on regulatory updates and changes related to CDI, HIM, utilization management and care management.Serves as a community resource and provides counsel to market CEO on medical and administrative matters related to medical practice and current clinical issues / affairs. The CMO oversees physician alignment and physician supply and demand for the campus. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. The CMO leads the Care Transformation Program to improve quality, increase patient safety, and decrease cost of care.

• Collaborates with the campus section chairpersons, campus Medical Chief of Staff, and contracted physicians to ensure that appropriate structure, policies and procedures are operational for accreditation and performance excellence
• Provides executive oversight for Associate CMO, medical director and medical staff services
• Develops, monitors, and evaluates performance/process improvement, disease management, utilization review activities, and standards to improve quality outcomes both clinically and administratively ensuring the highest standards in treatment and care of patients. Advocates the use of evidence-based medicine
• Establishes and implements standards and policies to ensure quality medical care while driving clinical outcomes for the campus. Works collaboratively with senior management, patient care leaders, and managers as well as staff to accomplish goals
• Serves as a member of the campus senior management team and assists in strategic development of initiatives and programs
• Consults and advises members of the medical staff on professionalism, quality and safety issues, and excessive or inappropriate utilization of resources
• Consults and advises as needed on risk management reviews, and/or patient’s grievances when working in collaboration with the campus Risk Management team
• Collaborates with medical staff leaders including department medical directors and elected medical staff leaders on hospital and patient safety issues. Assists in the moderation of major physician-to-physician, physician-to-staff, and physician-to-patient interactions in partnership with the campus Medical Chief of Staff and other medical staff leaders
• Ensures medical staff development plans and programs are implemented and aligned with those of the hospital. Promotes shared goals and teamwork in interactions with medical staff, clinical staff, and administration. Supports the clinical team and promotes individual growth among medical staff and clinical leaders.
• Participates in the annual operating and capital budget process by providing input
• Responsible for physician engagement strategies including supporting community physicians in physician recruitment and promoting programs which enhance physician satisfaction. Actively engaged in efforts to recruit medical staff members who will support the mission, vision, values, and purpose of AdventHealth.
• Provides support to and champions the organization’s infection prevention program. Acts as intermediary between the campus infection prevention coordinator and individual physicians and/or physician groups to resolve problems related to infection control practice issues
• Supports quality and safety initiatives of AdventHealth through education, standardization and implementation of system strategies
• Facilitates data driven activities that lower the cost of care including evaluation of use of supplies, devices, medications, and other physician preference items
• Serve as the medical liaison between the campus and the organization’s population health department with emphasis on operationalizing strategies that improve patient care across the continuum and outside the acute care setting
• Provide medical support and content expertise to partnerships with external stakeholders (private companies, local government) that are designed with the intent of improving the health of the community
• Provide support to internal and external communications teams and participate as needed on engagements with the media with the goal of educating the community on medical and public health topics that improve the health of the community
• Provides oversight for the medical service lines including strategic planning, accurate documentation, and multidisciplinary needs
• Regularly attends all relevant campus medical staff meetings, administrative team meetings, and other meetings where appropriate
• From a physician’s perspective, affirmatively provides counsel to senior management team discussions and action plans related to service changes, improvements, new service/program offerings inclusive of all operational and strategy decisions
• Takes a lead role on campus sentinel event teams. During an emergency, disaster, or catastrophic event, CMO may be assigned to any disaster service activity that promotes the protection of public health and safety
• Maintains current knowledge of accreditation bodies, State of Florida, AdventHealth, and any other relevant, regulatory, or reporting organizations standards on quality indicators and certification processes. Ensures compliance with all relevant licensing and accrediting bodies. Provides leadership and vision in the development of clinical guidelines and care pathways.
• Participates and leads campus Catalyst initiatives
• Provide strategic oversight and guidance for the facility’s patient and workforce safety, ensuring clear goals, effective governance structures, and leadership accountability
• Foster and sustain a facility-wide culture of safety that emphasizes psychological safety, continuous learning from harm and near-miss events, and meaningful engagement of patients, families, and the workforce

• Knowledge, Skills, and Abilities:
• Maintains current knowledge of accrediting bodies, State of Florida, AdventHealth, and any other relevant, regulatory, or reporting organizations standards on quality indicators and certification processes [Required]
• Working knowledge of medical informatics, applied statistical techniques, and analytical tools/processes [Required]
• Planning, goal setting and results measurement, budgeting, negotiation, operations management, and process improvement skills [Required]
• Current and up to date on hospital clinical quality, benchmarking, and best practices [Required]
• Well versed in managed care and health policy [Required]
• Ability to work effectively with hospital administration, staff, clinicians, physicians, and community members [Required]
• Effective communication, organization, leadership, and decision-making skills [Required]
• Proficient in use of office technology such as Microsoft Outlook, Word, and Excel [Required]

• Education:
• Doctor of medicine or Doctor of Osteopathic Medicine [Required]
• Master’s degree in Business Administration (MBA), Master’s degree in Public Health (MPH), or Master’s degree in Healthcare Administration (MHA) [Preferred]

• Work Experience:
• Minimum of ten (10) years professional, post-residency experience in direct patient care [Required]
• Minimum of five (5) years in an executive leadership role within a medium to large integrated health system [Required]
• Experience with designing effective clinical best practice patterns and clinical protocols to decrease inappropriate utilization and enhance quality outcomes [Required]
• Experience in developing data tools to evaluate clinical outcomes and an understanding of healthcare information technology [Required]
• If clinical work is part of this role, must be eligible to become a member of the AdventHealth Medical Staff [Required]
• Ten (10) years in a medical staff leadership role within a medium to large integrated health system [Preferred]
• Medical staff relations, quality measurement credentialing, and previous medical management experience [Preferred]

• Licenses and Certifications:
• Current, valid State of Florida license to practice medicine as a physician [Required]
• State of Florida board certified in an approved clinical specialty [Preferred]