24 rn utilization manager jobs found

Kaiser Permanente Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the...

Kaiser Permanente Job Summary: In addition to the responsibilities listed above, this position is also responsible for providing consultation and education related to clinical quality and patient safety, accreditation, regulatory and licensing (AR&L), risk management, and infection prevention and control; contributing to the evaluation, design, and development of evidence-based guidelines, principles, and/or programs related to area of work as well as facilitating implementation efforts to reduce variation in clinical practice and optimize patient outcomes; assisting with the collection, analysis, report development, and presentation of clinical data for a variety of users including for state, federal, and local agencies; helping to provide education regarding the interpretation of compliance methods when preparing for regulatory reviews, the interpretation of regulatory requirements, and regional project goals; monitoring, reporting, and developing mitigation plans for...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: We are looking for an experienced Nurse Care Manager to work remotely from within the greater Baltimore, Maryland metropolitan area with both Adult and Pediatric members. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. Under minimal supervision, the Nurse Care Manager researches and analyzes the Adult and Pediatric member's medical and behavioral health needs and healthcare cost drivers. The Nurse Care Manager works closely with the member / members family and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. ESSENTIAL FUNCTIONS: Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with member, family and providers to...

Sharp HealthCare Hours : Shift Start Time: 8 AM Shift End Time: 4:30 PM AWS Hours Requirement: 8/40 - 8 Hour Shift Additional Shift Information: Weekend Requirements: No Weekends On-Call Required: No Hourly Pay Range (Minimum - Midpoint - Maximum): $62.230 - $80.300 - $89.930 The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices. What You Will Do Timely and appropriate coordination of quality healthcare services to meet an individual's specific health needs in a cost-effective manner to promote positive outcomes. Involves a collaborative process of assessment, planning,...

Sharp HealthCare Hours: Shift Start Time: 8 AM Shift End Time: 4:30 PM AWS Hours Requirement: 8/80 - 8 Hour Shift Additional Shift Information: Weekend Requirements: As Needed On-Call Required: No Hourly Pay Range (Minimum - Midpoint - Maximum): $61.740 - $70.170 - $90.160 The stated pay scale reflects the range as defined by the collective bargaining agreement between Sharp HealthCare and Sharp Professional Nurses Network, United Nurses Associations of California/Union of Health Care Professionals, NUHHCE, AFSME, AFL-CIO. Placement within the range is based on years of RN experience. What You Will Do The RN CM I assesses, develops, implements, coordinates and monitors a comprehensive plan of care for each patient/family in collaboration with the physician, social worker and all members of the interdisciplinary team in the inpatient and emergency department patient care areas. This position requires the ability to...

Sharp HealthCare Hours: Shift Start Time: 8 AM Shift End Time: 4:30 PM AWS Hours Requirement: 8/80 - 8 Hour Shift Additional Shift Information: Weekend Requirements: No Weekends On-Call Required: No Hourly Pay Range (Minimum - Midpoint - Maximum): $67.860 - $78.740 - $89.620 The stated pay scale reflects the range as defined by the collective bargaining agreement between Sharp HealthCare and Sharp Professional Nurses Network, United Nurses Associations of California/Union of Health Care Professionals, NUHHCE, AFSME, AFL-CIO. Placement within the range is based on years of RN experience. What You Will Do To provide management of patients transitioning from the inpatient care setting to home. Involves patient assessment and coordination of services in the immediate post discharge phase. Addresses care coordination, facilitation of referrals to providers, vendors, and community services, disease education, caregiver...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: a { text-decoration: none; color: #464feb;}tr th, tr td { border: 1px solid #e6e6e6;}tr th { background-color: #f5f5f5;} This role supports the Dual Special Needs Population (DSNP) in Maryland. Under minimal supervision, the Care Manager conducts thorough research and analysis of members medical and behavioral health needs, along with the key drivers influencing healthcare utilization and costs. The Care Manager partners closely with members and the interdisciplinary care team to develop and implement person-centered plans of care that promote a positive member experience, improved health outcomes, and costeffective service delivery. We are seeking a bilingual Care Manager to enhance communication, cultural responsiveness, and engagement with our diverse DSNP member population. This position is remote, with the expectation that the selected candidate resides within the greater Baltimore metropolitan area....

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and lines of business in order to formulate a professional response to the appeal request. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. ESSENTIAL FUNCTIONS: Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: We are looking for an experienced professional to live and work remotely from within the greater Baltimore/Washington metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. Under minimal supervision, the Care Manager researches and analyzes a member's medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. ESSENTIAL FUNCTIONS: Identifies members with acute/complex medical and/or behavioral health conditions. Engages telephonically with member, family, and providers to develop a comprehensive plan of care to address the members needs at various stages along the care continuum....

Sharp HealthCare Hours : Shift Start Time: Variable Shift End Time: Variable AWS Hours Requirement: 8/40 - 8 Hour Shift Additional Shift Information: Variable start/end day shift + 2 weekend shifts per month Weekend Requirements: As Needed On-Call Required: No Hourly Pay Range (Minimum - Midpoint - Maximum): $53.570 - $69.120 - $77.410 The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant's years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices. What You Will Do Responsible for coordination of services utilizing a multidisciplinary plan to ensure the effective and efficient consumption of available health care resources while...

CareFirst BlueCross BlueShield Resp & Qualifications (Maryland-DC-Northern VA) PURPOSE: Under minimal supervision, the Care Manager researches and analyzes a member's medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. We are looking for an experienced professional to work remotely from within the greater Baltimore/Washington DC metropolitan areas. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. ESSENTIAL FUNCTIONS: Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with member, family and providers to develop a comprehensive plan of care to address the members needs at...

Aledade The Population Health Manager is a collaborative, strategic clinical leader who helps drive the success of Aledade's value-based care initiatives by championing health equity and leveraging data-driven insights. This role specifically focuses on high-impact, low-performing outlier practices that have a unique opportunity to improve the population health of their communities by addressing health equity. This role facilitates high-level change management, performance improvement, and the implementation of specialized programs, such as those related to Social Determinants of Health (SDOH). The Manager is an innovative self-starter responsible for developing new population health initiatives and forging external partnerships to secure resources for patients. This role must gain credibility with multiple stakeholders in order to facilitate the implementation of strategic plans that optimize patient outcomes. This position requires 50% travel to partner practices to...

Point32Health, Inc. Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about...

Point32Health, Inc. Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about...

Point32Health, Inc. Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: This role manages the appeal process for members and providers who appeal on behalf of members for Commercial lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State and Federal Regulatory fines and sanctions, avoid adverse exposure, reiterate the expectation of a fair and compliant appeal process for our membership, and support NCQA accreditation and the Divisional Goals for Care Management. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week. ESSENTIAL FUNCTIONS: Develops, establishes and implements a compliant appeal process with dynamic goals resulting in the full and...

STRATEGIC STAFFING SOLUTIONS (S3) HAS AN OPENING! Strategic Staffing Solutions is currently looking for a Case Manager RN for one of our largest clients in Detroit, MI! Job Title: Case Manager RN Duration: 6 months Location: Detroit, MI Schedule: Remote (Must be local to Michigan) W2 pay rate: $38 hourly, no paid days off, no paid holidays. Medical coverage is available. 1-year contract with opportunity for extension and conversion 100% REMOTE Requires Current, active, and unrestricted Michigan Registered Nurse (RN) license. Even though the job is fully remote, the candidate must be licensed in the state of Michigan - not just any compact/multistate license unless it specifically includes Michigan. ENGAGEMENT DESCRIPTION: The Case Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person-centric care management program to a diverse health plan population with a variety of health and social needs. They serve as the single...

Kaiser Permanente Job Summary: Responsible for optimizing quality and efficiency of care for hospitalized members by conducting daily utilization and quality reviews, discharge planning, and care coordination. Collaborates with physicians and multidisciplinary teams, developing safe discharge plans, and ensuring compliance with all relevant regulations. The role promotes high customer satisfaction and achieves desired utilization and quality outcomes for the population served. Essential Responsibilities: Utilizes established criteria, to perform daily inpatient review activities, including prospective, concurrent, and retrospective utilization review for all members requiring inpatient admission. Performs an admission utilization review upon admission. Assesses discharge planning needs and documents assessment using designated tools in EMR for all new inpatient admissions within 24 hours and begins the discharge planning process immediately. Conducts a concurrent...

Kaiser Permanente Job Summary: Responsible for carrying out precertification and medical necessity reviews on all designated referrals as well as targeted outpatient procedures, services and inpatient admissions. The activities will include telephonic review for medical necessity of the RN designated targeted outpatient procedures, services and inpatient admissions, as well as referrals, utilizing established criteria and guidelines, retrospective ED reviews. In addition, they will perform eligibility and benefit reviews as necessary, identification of patients for case management, quality improvement reviews, and communicate with inpatient care coordinators, case managers, the SNF/Rehab care coordinator, members, providers, Customer Service, Claims, Contracts and Benefits - Appeals, Risk Management. Essential Responsibilities: Responsible for the day to day precertification and review activities as outlined above. Utilizes established criteria to perform precertification...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: We are looking for RNs in the Washington, DC and Northern Virginia area to be part of our Onsite Clinical Navigator team. The Onsite Clinical Navigator (RN) embedded at a partnering hospital will conduct concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Onsite Clinical Navigator will leverage proficiency in established MCG, in addition to administrative/regulatory considerations, to determine medical necessity, appropriate level(s) of care and case management to engage members/enrollees, their families and other support systems in discharge planning. The role will function as a liaison working onsite at the assigned hospital up to 5 days per week and occasional weekend work may also be required, both at management's sole...