Utilization Review Coordinator remote jobs

Responsive recruiter KENTECH Consulting Inc. is an award-winning background technology screening company. We are the creators of innovative projects such as eKnowID.com, the first consumer background checking system of its kind, and ClarityIQ, a high-tech and high-touch investigative case management system. MISSION We're on a mission to help the world make clear and informed hiring decisions. VALUE In order to achieve our mission, our team exhibits the behaviors and core values aligned with it. *********************************** Customer Focused: We are customer-focused and results-driven. Growth Minded: We believe in collaborative learning and industry best practices to deliver excellence. Fact Finders: We are passionate investigators for discovery and truth. Community and Employee Partnerships: We believe there is no greater power for transformation than delivering on what communities and employees care about. IMPACT As a small, agile company, we seek high performers who appreciate that their effort will directly impact our customers and help shape the next evolution of background investigations. Are you a highly organized and detail-oriented professional who thrives in a fast-paced environment? Do you enjoy ensuring smooth communication between departments and maintaining accurate, precise information? KENTECH Consulting Inc. is seeking a customer-focused Intake Specialist to serve as the first point of contact in our background investigation process. In this role, you will play a critical part in ensuring timely and efficient service delivery by facilitating seamless case intake and handoff. Key Responsibilities • Case Intake and Data Management, serve as the initial point of contact for incoming background check requests, ensuring accurate data capture and case setup. • Interdepartmental Coordination, work closely with Investigative Analysts and Verifications teams to ensure smooth handoffs and consistency in service delivery. • Data Validation and Accuracy, review and validate incoming client information and address missing details to minimize delays. • Case Management and Record Keeping, maintain accurate intake records in ClarityIQ, our case management system. • Prioritization and Time Management, manage intake tasks based on client requirements, service standards, and deadlines. • Client Communication and Support, engage with clients to clarify initial information and support strong relationships and proactive communication. • Process Improvement, contribute to enhancements in intake processes to improve efficiency and client satisfaction. Qualifications and Experience • One or more years of experience in intake, customer service, or administrative roles. Experience in healthcare, social services, legal, or background screening is a plus. • Strong attention to detail and accuracy in data entry and record keeping. • Effective written and verbal communication skills with a customer-first mindset. • Tech savvy, comfortable using case management systems or CRM software. Experience with ClarityIQ is a plus. • Ability to adapt to evolving processes and priorities in a dynamic work environment. Desired Soft Skills • Critical thinking and the ability to evaluate information accurately and make informed decisions. • Clear communication in both verbal and written interactions with clients and team members. • Strong attention to detail and commitment to accurate data handling. • Team collaboration and the ability to work cooperatively across departments. • Problem solving with a proactive approach to addressing challenges and improving processes. Why Join KENTECH? • Remote and flexible work that allows you to support a fast-growing team. • Professional development opportunities and training for career growth. • The chance to make a meaningful impact in a mission-driven company that values accuracy, efficiency, and innovation. Apply Now If you are a detail-oriented professional with a passion for client service and operational efficiency, we want to hear from you. KENTECH Consulting Inc. is an equal opportunity employer. We celebrate diversity and remain committed to fostering an inclusive workplace. This is a remote position. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. 🌐 WHO WE ARE KENTECH Consulting, Inc. is a premier U.S.-based background investigation solutions firm and licensed Private Detective Agency. Our team of investigative experts blends cutting-edge technology with industry insight to deliver fast, accurate, and comprehensive reports. With deep cross-industry experience, we provide fully compliant investigative services that meet the high demands of today's business environment. 🔎 WHAT WE DO We offer customized background screening solutions tailored to meet the needs of diverse industries. Our advanced tools and digital platforms allow us to conduct background and security checks up to 75% faster than traditional methods. With real-time access to over 500 million records, KENTECH is a trusted authority in background checking technology across the U.S. 🌟 OUR VISION To help the world make clear and informed decisions. 🎯 OUR MISSION To deliver fast, accurate, and secure background investigations on a global scale-supporting safer hiring decisions and stronger communities. 🚀 CAREERS AT KENTECH We're building a team of remarkable individuals who are: ✅ Critical thinkers and problem solvers who see challenges as opportunities ✅ Driven professionals who create meaningful impact through their ideas and results ✅ Mission-driven collaborators who believe in the power of digital identity to create safer environments ✅ Naturally curious and eager to innovate in an ever-changing landscape ✅ Team players who believe in the value of camaraderie, laughter, and high standards 💼 WHO THRIVES HERE? People who never back down from a tough challenge Professionals who bring their best every day-and uplift others around them Individuals who value purpose, performance, and a good laugh Teammates who want to shape the future of digital security and identification You, if you're reading this and thinking: “This sounds like my kind of place.” 🎉 YOUR NEXT CHAPTER STARTS HERE Ready to do work that matters with people who care? Explore our current openings-your future team is waiting.

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. The Manager, Utilization Management (UM) Coordination, oversees non-clinical inpatient and pre-service operations under the direction of the Director of Utilization Management. This role provides leadership to UM Supervisors and their coordinator teams to ensure timely, accurate, and compliant processing of authorizations and referrals in accordance with CMS and organizational standards. The Manager drives operational efficiency, staff development, and process improvement while collaborating with internal departments to support continuity of care and overall service quality. Job Responsibilities: Provide operational leadership and direction to two Utilization Management Supervisors overseeing non-clinical coordinator teams supporting both Inpatient and Pre-Service workflows. Lead the teams meet established turnaround times (TATs), quality, and productivity standards for authorization processing, referral routing, and related UM functions. Oversee staffing allocation, scheduling, and workload balancing between inpatient and pre-service units to maintain consistent service levels. Conduct regular one-on-one meetings with supervisors to review performance metrics, workflow barriers, and staff development needs. Own the daily operations to ensure timely and accurate completion of authorizations, correspondence, and documentation in compliance with CMS, NCQA, and organizational standards. Identify process inefficiencies and implement corrective actions to improve turnaround, accuracy, and staff productivity. Lead root-cause analyses for escalated operational issues and coordinate corrective action plans. Responsible for all the accuracy of all UM workflows, systems, and reporting dashboards to support data-driven decision making. Oversee the development and delivery of training materials, competency assessments, and reference guides to promote consistent and compliant practices. Mentor Supervisors to build leadership capacity, coaching them on staff management, delegation, and performance improvement techniques. Drive onboarding, cross-training, and refresher sessions are regularly conducted to support staff versatility across inpatient and pre-service functions. Manage all team activities adhere to CMS and organizational policies related to Utilization Management, confidentiality, and member communication standards. Oversee internal audit reviews and collaborate with the Quality and Compliance teams to address findings and implement improvement plans. Direct that all letters and communications use approved templates and standardized language for UM determinations and continuity-of-care requirements. Participate in internal and external audits, Medical Services Committee meetings, and other regulatory reviews as required. Review and analyze key performance indicators (KPIs), including volume, turnaround time, accuracy, and productivity reports; present trends and improvement strategies to leadership. Support the preparation and submission of monthly UM reports, dashboard summaries, and Medical Services Committee deliverables. Leverage data to identify training needs, process gaps, and operational trends impacting service delivery or compliance. Serve as a liaison between UM, Case Management, Provider Relations, and Claims departments to streamline interdepartmental communication and issue resolution. Collaborate with network providers and internal teams to clarify authorization processes and ensure alignment with benefit and policy criteria. Participate in internal workgroups or initiatives to improve system functionality, workflow automation, and reporting enhancements. Assist with the development, implementation, and monitoring of UM-related initiatives and special projects (e.g., claims review process, continuity-of-care tracking, or performance optimization programs). Evaluate and revise UM policies and procedures to align with evolving regulatory standards and organizational goals. Support readiness activities for CMS audits and other accreditation requirements. Perform other related functions and special assignments as directed by senior leadership. Core Competencies: Leadership & Talent Development - Demonstrates the ability to lead through others by developing and empowering supervisors and staff. Fosters a culture of accountability, engagement, and continuous improvement within the UM department. Operational Management - Applies strong organizational and analytical skills to oversee workflow execution, resource allocation, and performance metrics across inpatient and pre-service teams. Regulatory & Compliance Expertise - Maintains in-depth knowledge of CMS regulatory standards, confidentiality requirements, and UM protocols to ensure full compliance and audit readiness. Analytical Thinking & Decision-Making - Uses data to identify trends, evaluate outcomes, and implement process improvements that enhance accuracy, turnaround times, and service quality. Communication & Collaboration - Communicates clearly across all organizational levels; partners effectively with Clinical Operations, Provider Relations, Case Management, and Claims to resolve issues and align priorities. Process Improvement & Innovation - Continuously evaluates operational workflows and implements efficiency strategies that support organizational goals and member satisfaction. Member & Service Orientation - Demonstrates commitment to delivering high-quality service, ensuring that UM processes support positive member experiences and continuity of care. Change Management - Adapts to evolving regulatory, system, and organizational needs while leading teams through process transitions and new initiatives effectively. Supervisory Responsibilities: Oversees assigned staff. Responsibilities include: recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and performance management. Job Requirements: Experience Required: Minimum (4) years of related experience in a managed care setting and a minimum (3) years of recent and related supervisory experience Education Required: Highschool Diploma or GED Required Preferred: Bachelor's Degree or higher Other: Strong knowledge of Medicare Managed Care Plans Proficient in Microsoft Word, Excel, and Outlook; advanced Excel skills preferred (pivot tables, formulas, data visualization, and reporting functions for performance tracking and analysis). Experience leading and sustaining process improvement initiatives within healthcare operations to enhance efficiency, compliance, and service quality. Communication and Interpersonal Skills - Excellent written and verbal communication skills; able to build and maintain collaborative relationships with diverse teams, including leadership, staff, and external partners. Analytical and Reasoning Skills - Strong analytical thinking with the ability to define problems, collect and interpret data, establish facts, draw valid conclusions, and develop actionable solutions. Problem-Solving and Organizational Skills - Demonstrated ability to prioritize multiple tasks, manage time effectively, and maintain accuracy in a fast-paced, dynamic environment. Data and Report Analysis - Ability to interpret, analyze, and present statistical and operational reports to support decision-making and performance monitoring. Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. Pay Range: $70,823.00 - $106,234.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation. *DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at ******************************* If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email ******************.

The Utilization Review Coordinator ensures efficient and effective management of utilization review processes, including denials and appeals activities. This role collaborates with payers, hospital staff, and clinical specialists to secure timely authorizations for hospital admissions and extended stays. The Utilization Review Coordinator monitors and documents all authorization activities, assists with process improvement initiatives, and serves as a key liaison to reduce denials and optimize patient outcomes. Essential Functions Submits initial assessments, continued stay reviews, and payer-requested documentation, ensuring compliance with policies, regulations, and payer requirements to establish medical necessity. Communicates with commercial payers to provide concise and accurate information to secure timely authorizations and reduce potential denials, utilizing input from the Utilization Review Clinical Specialist. Monitors and updates case management software with documentation of escalations, avoidable days, authorization numbers, denials, and payer interactions to ensure accurate records. Coordinates Peer-to-Peer discussions for unresolved concurrent denials, ensuring the process aligns with hospital, corporate, and payer requirements. Documents outcomes in case management systems. Reviews and closes out cases after patient discharge, ensuring all required documentation is complete and understandable for billing and future audits. Places cases on hold as necessary to resolve pending authorizations or reviews. Maintains performance metrics aligned with Key Performance Indicators (KPIs) for the Utilization Review Service Line. Serves as a key contact for facility and payer representatives, fostering effective communication and collaboration to resolve issues promptly. Participates in training initiatives within the department, supporting onboarding and skill development for team members. Responds promptly to phone calls, faxes, and insurance portal requests, providing high standards of customer service and satisfaction. Escalates issues to the manager as appropriate and provides recommendations for improving operational efficiency and outcomes. Ensures accurate and timely communication of hospital stay authorizations, denials, and delays to all relevant stakeholders. Performs other duties as assigned. Maintains regular and reliable attendance. Complies with all policies and standards. Qualifications H.S. Diploma or GED required Bachelor's Degree preferred 0-2 years of work experience in utilization review, hospital admissions or registration required 1-3 years of work experience in an office, processing center, or similar environment preferred Knowledge, Skills and Abilities Strong knowledge of utilization management principles, payer requirements, and healthcare regulations. Proficiency in case management systems and technology resources for authorization tracking and documentation. Excellent communication and interpersonal skills to interact effectively with payers, clinicians, and administrative staff. Critical thinking and problem-solving skills to analyze and resolve authorization and denial issues. Strong organizational skills to manage multiple priorities and meet deadlines. Attention to detail for accurate documentation and process adherence. Ability to train and support team members, fostering a collaborative and productive environment.

Flexible Independent Contractor (1099) Opportunity INDIANA State Medical License required Founded in 1983, Medical Review Institute of America (MRIoA) is a nationally recognized Independent Review Organization (IRO) specializing in technology-driven utilization management and clinical medical review solutions. We're a leader in Peer and Utilization Reviews, known for excellence and continuous improvement. THE OPPORTUNITY: We are currently seeking Board-Certified Internal Medicine physicians with a Geriatric Fellowship to conduct independent Utilization Reviews. This is a flexible, fully remote opportunity requiring just 1-2 hours per week-with no minimum commitment. ADDITIONAL INFORMATION: Work remotely from anywhere in the US (Per HIPPA Regulations patient records cannot leave the US). Covered under MRIoA's Errors and Omissions policy. Independent Contractor (1099) opportunity. Workers are required to adhere to all applicable HIPAA regulations and company policies and procedures regarding the confidentiality, privacy, and security of sensitive health information. California Consumer Privacy Act (CCPA) Information (California Residents Only): Sensitive Personal Info: MRIoA may collect sensitive personal info such as real name, nickname or alias, postal address, telephone number, email address, Social Security number, signature, online identifier, Internet Protocol address, driver's license number, or state identification card number, and passport number. Data Access and Correction: Applicants can access their data and request corrections. For questions and/or requests to edit, delete, or correct data, please email the Medical Review Institute at ************. Must have a Medical Degree MD or DO Must have a current INDIANA unencumbered medical license Current Board Certification in Internal Medicine with a Geriatric Fellowship Must have 5 years of clinical experience residency to be included Daytime availability is required for peer-to-peer conversations

Who We Are Founded in 1965, UC Irvine is a member of the prestigious Association of American Universities and is ranked among the nation's top 10 public universities by U. S. News & World Report. The campus has produced five Nobel laureates and is known for its academic achievement, premier research, innovation and anteater mascot. Led by Chancellor Howard Gillman, UC Irvine has more than 36,000 students and offers 224 degree programs. It's located in one of the world's safest and most economically vibrant communities and is Orange County's second-largest employer, contributing $7 billion annually to the local economy and $8 billion statewide. To learn more about UC Irvine, visit www. uci. edu. The NCI-designated Chao Family Comprehensive Cancer Center (CFCCC) is a campus-wide multidisciplinary matrix organization whose goal is to promote and enhance cancer-relevant research and patient care at UC Irvine. The CFCCC provides research resources to its ~175 members engaged in research and offers multidisciplinary cancer care to its patients. Your Role on the Team Under the direction of the Protocol Review Manager, the Protocol Review and Monitoring (PRM) coordinator is position is responsible for the coordination of Cancer Center committees including Disease Oriented Teams (DOTs), the Protocol Review and Monitoring Committee (PRMC), and the Data Safety and Monitoring Board (DSMB). The DOTs currently include, Neurological Oncology, Hematologic Malignancies, Gynecological, Genitourinary, Gastrointestinal, Skin, and Breast with additional DOTs being initiated, as needed. Clinical research committee coordination responsibilities include creating meeting agendas, developing complex correspondence to Principal Investigators (PIs), conducting follow-up activity on action items in a timely manner, outreaching to PIs and clinical research coordinators for research accrual information, and writing complex meeting minutes for scientific and clinical meeting deliberations. The PRM is responsible for appropriately triaging protocols through the clinical research committees and providing overall committee support. The individual must accurately maintain clinical trial information in the clinical trial management system, OnCore, and adhere to both institutional policies and National Cancer Institute requirements. Other additional duties include reporting and registering clinical trials to the NCI's Clinical Trial Reporting Program (CTRP) for accrual information and the clinicaltrials. gov registry for study outcome information. What It Takes to be Successful Required: Demonstrated experience providing high level administrative support to faculty members Ability to draft clear, concise correspondence including editing, correct format and grammar, spelling and syntax for complex and scientific meetings Demonstrated high-level communication skills to convey information in a clear and concise way, synthesizing information and presenting it to others Demonstrated ability to make sound decisions and employ effective problem-solving techniques Ability to interact with the public, faculty, and staff. Demonstrated problem solving capabilities to resolve concerns that arise unexpectedly Demonstrated ability to research, properly evaluate information, and prepare concise, well organized reports, summaries, and correspondence Demonstrated ability to organize and prioritize a complex and dynamic workload Ability to multitask and meet deadlines, despite interruptions Ability to independently exercise discretion and sound judgment Ability to work collegially and cooperatively in a small office and to establish and maintain cooperative working relationships Demonstrated skill in interacting with persons of various social, cultural, economic and educational backgrounds Ability to prioritize assignments and achieve high productivity/quality with short time frames, under rigid deadlines, and /or in environments with frequent workload changes and competing demands Skill in working independently, taking initiative and following through on assignments Ability to maintain confidentiality of records and information Ability to compile data from various sources, analyze data, and prepare reports. Ability to work both independently and as part of team Ability to take initiative and demonstrate strong commitment to duties Ability to think critically and to compile and analyze data Ability to analyze problems, implement solutions and multitask Ability to work within a deadline-driven structure Demonstrated experience in maintaining flexibility and adaptability while implementing institutional change High level of integrity and honesty in maintaining confidentiality Foster and promote a positive attitude and professional appearance Strong attention to detail Working knowledge of computer software including Microsoft Office (Outlook, Word, Excel, and PowerPoint HS graduation and sufficient experience and demonstrated skills to successfully perform the assigned duties and responsibilities. Experience coordinating operational logistics for high-level scientific and clinical meetings utilizing teleconference and web conference technology. Preferred: NCI Comprehensive Cancer Center committee administration experience Extensive experience with various types of human subject clinical trials i. e. , National Group, Industrial, and Investigator-authored. Experience with clinical trial management systems, preferably OnCore. Special Conditions: Requires coordinating some committee meetings outside of normal business hours along with travel back and forth to the Irvine and Orange campuses. Total Rewards In addition to the salary range listed below, we offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits. Conditions of Employment: The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment: Background Check and Live Scan Employment Misconduct* Legal Right to work in the United States Vaccination Policies Smoking and Tobacco Policy Drug Free Environment *Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer. The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements. California Child Abuse and Neglect Reporting Act E-Verify Pre-Placement Health Evaluation Details of each policy may be reviewed by visiting the following page - *********** uci. edu/new-hire/conditions-of-employment. php Closing Statement: The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC Anti-Discrimination Policy. We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable, and welcoming. UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact Human Resources at ************** or eec@uci. edu. Consideration for Work Authorization Sponsorship Must be able to provide proof of work authorization

Hi, we're Oscar. We're hiring a Physician Reviewer to join our Utilization Management team. Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves-one that behaves like a doctor in the family. About the role: You will determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines. Hours: 8am - 5pm in your local time zone Call rotation - 1 weekend every 16 weeks You will report into the Associate Medical Director, Utilization Management. Work Location: This is a remote position, open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office, occasional travel may be required for team meetings and company events. #LI-Remote Pay Transparency: The base pay for this role is: $211,200 - $ 277,200 per year. You are also eligible for employee benefits, participation in Oscar's unlimited vacation, and annual performance bonuses. Responsibilities: Provide timely medical reviews that meet Oscar's stringent quality parameters. Provide clinical determinations based on evidence-based criteria and Oscar internal guidelines and policies, while utilizing clinical acumen. Clearly and accurately document all communication and decision-making in Oscar workflow tools, ensuring a member could easily reference and understand your decision (Flesch-Kincaid grade level). Use correct templates for documenting decisions during case review. Meet the appropriate turn-around times for clinical reviews. Receive and review escalated reviews. Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research. Compliance with all applicable laws and regulations Other duties as assigned Requirements: Board certification as an MD or DO Licensed in FL or NC and/or active Interstate Medical Licensure Compact (IMLCC) or eligible to apply for IMLCC. 6+ years of clinical practice 1+ years of utilization review experience in a managed care plan (health care industry) Bonus points: Licensure in multiple Oscar states BC in Cardiology, Radiation/Oncology, or Neurology Experience with care management within the health insurance industry. Willing and able to obtain additional state licensure as needed, with Oscar's support This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here. At Oscar, being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. We're on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives. Pay Transparency: Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education, and experience. Full-time employees are eligible for benefits including: medical, dental, and vision benefits, 11 paid holidays, paid sick time, paid parental leave, 401(k) plan participation, life and disability insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts. Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications, without regard to applicant's disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team (accommodations@hioscar.com) to make the need for an accommodation known. California Residents: For information about our collection, use, and disclosure of applicants' personal information as well as applicants' rights over their personal information, please see our Privacy Policy.

Hello, Thank you for your interest in career opportunities with the University of Mississippi Medical Center. Please review the following instructions prior to submitting your job application: Provide all of your employment history, education, and licenses/certifications/registrations. You will be unable to modify your application after you have submitted it. You must meet all of the job requirements at the time of submitting the application. You can only apply one time to a job requisition. Once you start the application process you cannot save your work. Please ensure you have all required attachment(s) available to complete your application before you begin the process. Applications must be submitted prior to the close of the recruitment. Once recruitment has closed, applications will no longer be accepted. After you apply, we will review your qualifications and contact you if your application is among the most highly qualified. Due to the large volume of applications, we are unable to individually respond to all applicants. You may check the status of your application via your Candidate Profile. Thank you, Human Resources Important Applications Instructions: Please complete this application in entirety by providing all of your work experience, education and certifications/ license. You will be unable to edit/add/change your application once it is submitted. Job Requisition ID:R00046700Job Category:NursingOrganization:Utilization ReviewLocation/s:Main Campus JacksonJob Title:RN - Utilization Reviewer - Coordinated CareJob Summary:Accountable to perform utilization management services for designated patient case load, including prospective, concurrent, retrospective, and denial management reviews by applying clinical protocols and review medical necessity criteria. Reports quality of care issues identified during the um process to the appropriate manager. To perform job duties in accordance with the medical center's purpose.Education & Experience Four (4) years RN experience, one (1) year of which must have been in performance improvement, utilization review, or case management. CERTIFICATIONS, LICENSES OR REGISTRATION REQUIRED: Valid RN license. CPUM (certified professional in utilization management), ACM (accredited case manager), or CCM (certified case manager) preferred. Knowledge, Skills & Abilities Knowledge of the aspects of utilization review. Excellent interpersonal verbal and written communication and negotiation skills. Skills in the use of personal computers and related software applications. Ability to gather data, compile information, and prepare reports. Ability to identify process improvements. Good working knowledge of and understanding of medical procedures and diagnoses, procedure codes, including ICD-10, CPT, and DSM-IV codes. Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement. Ability to work independently and exercise sound judgement in interactions with physicians, payers, and patients and their families. Demonstrate commitment to the organ Ization's mission and the behavioral expectations in all interactions and in performing all job duties. Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and commitment to continuous quality improvement (CQI) process. Independent, focused and follow written instructions. Ability to use medical necessity guidelines with minimal supervision. Equipped to work remotely to include hardware with high speed internet via cable and Windows 10 RESPONSIBILITIES: Performs all aspects of prospective, concurrent, retrospective and denials review for individual cases to include benefit coverage issues, medical necessity appropriate level of care (setting) and mandated services. Assists in the collection and reporting of financial indicators including case mix, los, cost per case, excess days, resource utilization, readmission rates, denials and appeals. Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction. Collects, analyzes and addresses variances from the plan of care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes. Collects delay and other data for specific performance and/or outcome indicators as determined by administrator - resource management. Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning, care transitions and care coordination). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. Applies approved clinical appropriateness criteria to monitor appropriateness of admissions, and continued stays, and documents findings based on department standards. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Refers cases and issues to care management physician advisor in compliance with department procedures and follows up as indicated. Communicates with third party payers to facilitate covered day reimbursement certification for assigned patients. Discusses payor criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. Uses quality screens to identify potential issues and forwards information to clinical quality review department. Completes utilization management and quality screening for assigned patients. Works collaboratively and maintains active communication with physicians, nursing, and other members of the inter-disciplinary care team to effect timely, appropriate patient management and eliminate barriers to efficient delivery of care in the appropriate setting. Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Utilizes conflict resolution skills as necessary to ensure timely resolution of issues. Collaborates with physicians and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis: completion and reporting diagnostic testing; completion of treatment plan and discharge plan; modification of plan of care, as necessary, to meet the ongoing needs of the patient; communication to third party payers and other relevant information to the care team; assignment of appropriate levels of care; completion of all required documentation in epic screens and patient records. Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice. Promotes individual professional growth and development by meeting requirements for mandatory/ continuing education, skills competency, supports department- based goals which contribute to the success of the organization; serves as preceptor, mentor, and resource to less experienced staff. Actively participates in clinical performance improvement activities The duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time. Environmental and Physical Demands: Requires occasional exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold, no handling or working with potentially dangerous equipment, occasional working hours beyond regularly scheduled hours, occasional travelling to offsite locations, occasional activities subject to significant volume changes of a seasonal/clinical nature, occasional work produced is subject to precise measures of quantity and quality, occasional bending, occasional lifting/carrying up to 10 pounds, occasional lifting/carrying up to 25 pounds, no lifting/carrying up to 50 pounds, no lifting/carrying up to 75 pounds, no lifting/carrying up to100 pounds, no lifting/carrying 100 pounds or more, no climbing, no crawling, occasional crouching/stooping, no driving, occasional kneeling,occasional pushing/pulling, occasional reaching, frequent sitting,occasional standing,occasional twisting, and frequent walking. (Occasional-up to 20%, frequent-from 21% to 50%, constant-51% or more) Time Type:Part time FLSA Designation/Job Exempt:NoPay Class:HourlyFTE %:100Work Shift:Benefits Eligibility:Grant Funded:Job Posting Date:11/5/2025Job Closing Date (open until filled if no date specified):

At Luminare Health , our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job SummaryThe Physician Review Coordinator is primarily responsible for initiation and oversight of the Healthcare Management Division's physician-level review process with Independent Review Organizations. Additionally, when business needs warrant, the individual conducts medical necessity reviews utilizing evidence-based medical criteria.Required Job Qualifications: Active RN License required Minimum three years of experience in a clinical setting Active MCG UM/CM Certification or obtain MCG UM/CM Certification within 6 months of hire Possess strong time management and organizational skills Ability to work independently and complete tasks in a timely manner, reprioritizing workload to meet customer and business needs Willingness to adjust and adapt to meet the business needs in an atmosphere that sometimes requires rapid change Comfort with telephonic and written communications with all levels of leadership within the organization, providers, IROs and business contacts in an efficient, professional manner Excellent customer service and interpersonal skills Comfort with using electronic applications including electronic documentation system and the ability to accurately document electronically while engaging callers or reviewing medical documents Excellent verbal and written communication skills Ability to use commonsense understanding to carry out instructions furnished in written, oral or diagram form Demonstration of excellent critical thinking skills to deal with problems in varying situations and reach reasonable solutions Proficient in MS Word, Excel and Outlook with the willingness to expand knowledge of the MS Suite of tools Preferred Job Qualifications: Utilization Management, Case Management, or Claims experience with a TPA or insurer highly preferred Bachelor of Science in Nursing Must reside in one of the following States: Illinois Montana New Mexico Oklahoma Texas Indiana Missouri Wisconsin Iowa Kansas North Carolina Pennsylvania Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! EEO Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Pay Transparency Statement: At Luminare, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for associates. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. Min to Max Range: $56,700.00 - $106,400.00 Exact compensation may vary based on skills, experience, and location.

At ABB, we help industries outrun - leaner and cleaner. Here, progress is an expectation - for you, your team, and the world. As a global market leader, we'll give you what you need to make it happen. It won't always be easy, growing takes grit. But at ABB, you'll never run alone. Run what runs the world. This Position reports to: Manufacturing Manager - NEMA Your role and responsibilities (Mandatory) In this role, you will have the opportunity to operate process equipment or machinery to convert raw materials or semi-finished parts into components or finished parts for a final product at the right time and with the required quality. Each day, you will execute the assigned tasks according to agreed workflows and in accordance with ABB standard processes and safety guidelines and reports any non-compliance. You will also showcase your expertise by operating machines in accordance with the operating manual, work schedule, and/or production order instructions. The work model for the role is: {onsite/hybrid/remote} {insert Linkedin #} This role is contributing to the {insert product group/business area/division/function} in {insert region}. Main stakeholders are {insert main stakeholder groups if available}. You will be mainly accountable for: Performing routine machinery set-up, adjustments, and repairing and fitting simple replacement parts. Ensuring regular standard maintenance of the equipment, tools set-up, programming activities, and troubleshooting and reporting issues, if any; and maintaining detailed records of machinery set-ups, repairs, and maintenance activities. Keeping track of approved, defective units, and final products. Our team dynamics (Optional) You will join a {insert adjectives - e.g. dynamic, talented, high performing} team, where you will be able to thrive. Qualifications for the role (Mandatory) You are immersed in / engaged in / absorbed in / highly skilled in/ you enjoy working with {relevant tools and methodologies} and the {insert relevant industry/sector} market Ability to demonstrate your experience in / Have established skills / advanced skills / You have {insert number of years} years of experience in {insert relevant field} (OPTIONAL: working as {insert relevant role} with {insert relevant products or technologies}) Possess an enhanced knowledge of / You are qualified in / Highly adept in {insert specialized software/platforms} You are passionate about / you are captivated by / you are innovative around {insert relevant soft skills} and {insert relevant soft skills} Degree in / Have a demonstrated track record in / Extensive knowledge of / Proven experience of {insert specific degree, qualification} in {insert subject} You are at ease communicating in {insert required language skill(s)} You hold current {insert required licenses} valid in {insert job location} and {insert country-specific VISA/work permit} {where required} What's in it for you? (Optional) Benefits (Optional) We also offer our employees the following benefits: Benefit 1 Benefit 2 Benefit 3 Benefit 4 Benefit 5 Local Specific Benefits (Open Field below - Optional) Locally, you can count on {Add local perks and benefits in text format} More about us (Mandatory) {Insert specific business area/division/service function or corporate function paragraph from common source material} {Insert country/location -specific boilerplate (1-2 sentences only)} {optional} {Insert country-specific legal statement e.g.: EEO/data privacy} {where required} {Insert PES (Pre-employment screening) sentence} {when required} {Insert local TP or hiring manager contacts if necessary} Guidelines: Please be aware: All fields in yellow should be populated with relevant information (based on Job description and the Kick-off form). All other text can also be modified if necessary, within the given guidelines. Text in bold is fixed and should not be edited or removed Reporting Manager section is mandatory both internally and externally, to be posted via eRec functionality “Your role and responsibilities” should be plain text followed by maximum 4 additional bullet points The “Qualifications for the role” section should include no less than five and no more than seven bullet points. These bullet points should be listed in order of importance for the success in the role Indicate the required language knowledge in the “Qualifications for the role” section whenever it is mandatory and/or applicable Information about “Licenses and visa/work permit” is optional, use this sentence wherever it is required In the “More about us” section you can add further legal statements/PES indications or Talent Partner contacts, for example Read more about the guidelines in the Guidelines doc available in the SharePoint We value people from different backgrounds. Could this be your story? Apply today or visit *********** to read more about us and learn about the impact of our solutions across the globe.

The once in a century transition to autonomous and electric vehicles is underway and will require a multi-trillion-dollar investment in energy and charging infrastructure, and the real estate to site it on. Terawatt is the leader in delivering large scale, turnkey charging solutions for companies rapidly deploying AV and EV fleets. Whether it's an urban mobility hub, or a carefully located multi-fleet hub for semi-trucks, Terawatt brings the talent, capabilities, and capital to create reliable, cost-effective solutions for customers on the leading edge of the transition to the next generation of transport. With a growing portfolio of sites across the US in urban hubs and along key logistics and transportation corridors and logistics hubs, Terawatt is building the permanent transportation and logistics infrastructure of tomorrow through a robust combination of capital, real estate, development, and site operations solutions. The company develops, finances, owns, and operates charging solutions that take the cost and complexity out of electrifying fleets. At Terawatt, we execute humbly and with urgency to provide tailored solutions for fleets that delight our clients and support the transition of transportation. Role Description Terawatt Infrastructure seeks an Energy and Utilities Manager for its Energy & Utility team. The Energy and Utilities Manager is a critical, independent contributor role responsible for developing and executing comprehensive utility engagement strategies throughout the entire development lifecycle of Terawatt Infrastructure projects. This individual will serve as the primary point of contact and subject-matter expert for all utility-related matters, ensuring seamless coordination and alignment among internal teams, including real estate, Development, Design-Construction, and Business Development. During the crucial site evaluation phase, the Energy and Utilities Manager will proactively engage with relevant utility providers to assess infrastructure availability, capacity, costs, and potential risks. This involves conducting thorough due diligence, analyzing utility maps and data, and collaborating with development teams to determine optimal site selection based on utility feasibility and economic considerations. The role extends to project engineering, where the Energy and Utilities Manager will actively contribute to the customer and utility design process, ensuring that utility requirements and specifications are integrated into project plans. This includes collaborating with teams to develop detailed utility layouts, load calculations, and energization designs. Furthermore, this individual will create realistic project schedules incorporating utility timelines for service connections, upgrades, and relocations, effectively mitigating potential delays. Budgeting is another key area of responsibility, requiring the Energy and Utilities Manager to develop and manage comprehensive utility budgets that cover connection fees, infrastructure upgrades, and ongoing service charges. This involves cost estimation, financial forecasting, and proactive identification of cost-saving opportunities. A significant aspect of this role involves skillfully negotiating and executing complex utility agreements and contracts, ensuring favorable terms and conditions for the organization. This includes managing relationships with utility providers, resolving disputes, and staying abreast of utility changes and industry best practices.Core Responsibilities Own key project milestones and deliverables, and manage delivery dates Collaborate closely and guide the Site Acquisition, Project Development, and Construction teams regarding preliminary utility-related engineering, design, and construction timelines. Understand and make critical recommendations regarding timing, cost, and economic trade-offs involved with site energization or interconnection for behind-the-meter generation. Be the owner of the dry utility space: interpret Utility Design Standards and draft dry utility space design via Bluebeam design tools. Be a problem solver when utility bottlenecks or failures are causing project delays. Inform the Company's energy and energization strategy through collaboration with the Real Estate, Project Development, Design & Construction, and Business Development teams. Identify, hire, and manage utility consultants as needed for projects. Preferred Qualifications Experience working with regulated and municipal electrical utilities in major US metro areas. A strong understanding of utility distribution/transmission planning and design, and electrical design standards. Electrical and site design experience Experience with the complete utility coordination process, from application to design to energization. Strategic thinking skills regarding business, operations, and technical challenges, coupled with the technical skills to execute project schedules, contracts, initiatives, and team objectives. Experience in estimating utility service costs. Experience with project development from greenfield or brownfield site acquisition to operational assets. We are building a team that represents a variety of backgrounds, perspectives, and skills. At Terawatt, we continuously strive to foster inclusion, humility, energizing relationships, and belonging, and welcome new ideas. We're growing and want you to grow with us. We encourage people from all backgrounds to apply. If a reasonable accommodation is required to fully participate in the job application or interview process, or to perform the essential functions of the position, please contact ********************************* . Terawatt Infrastructure is an equal-opportunity employer.

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates. Job Summary The Utilization Management Manager plays a vital role in ensuring patients have timely access to care by managing both front-end prior authorizations and in-house concurrent review authorizations. This position blends strong relationship-building skills with clinical knowledge to navigate complex payer requirements, streamline the authorization process, and support seamless patient transitions. From start to finish, this role drives the authorization process-reviewing prospective, retrospective, and concurrent medical records; coordinating with referring hospitals to secure prior authorizations; and partnering with case management teams at ScionHealth facilities to complete concurrent review authorizations. Acting as a navigator and liaison between Business Development, facility administration, managed care organizations, and payors, the specialist ensures determinations are communicated promptly and accurately to all relevant stakeholders. By combining attention to detail with proactive collaboration, the Utilization Management Manager safeguards revenue integrity, reduces delays, and supports the organization's mission of delivering exceptional patient care. This role actively contributes to quality improvement, problem-solving, and productivity initiatives within an interdisciplinary model, demonstrating accountability and a commitment to operational excellence. Essential Functions * Extrapolates and summarizes essential medical information to obtain authorization for admission and continued stay to/at ScionHealth Level of Care. * Prepares recommendations to sumbit timely request for reconsideration of denial determination in attempt to have denied authorization requests overturned. * Ensures authorization requests are processed timely to meet regulatory timeframes. * Reviews medical necessity assessments completed by case management, evaluating documentation for specific criteria related to severity of illness, and level of care appropriateness. * Generates written appeals to medical necessity-based payor denials for denials prior to admission and concurrent review authorizations. Appeal letters may be processed on behalf of the physician, combining clinical and regulatory knowledge in efforts to have consideration of authorization. * Documents authorization information in relevant tracking systems. * Effectively builds relationships with business development team, admissions team/clinical staff and managed care team, to coordinate the patient admission functions in keeping with the mission and vision of the hospital. * Supports review of patient referral for clinical and financial approval and/or escalation to leadership for approval following the Care Considerations grid. * Coordinates and facilitates pre-admission Prior Authorizations for patients from the referral sources: * Identifies /reviews medical record information needed from referring facility. * Applies appropriate clinical guidelines to pre-authorization determination process. * Communicates specific patient needs for equipment, supplies, and consult services as related to prior authorization requirements. * Acts as a liaison with the Business Development team through every stage of the authorization process through determination. * Initiates appeals process as appropriate. * Facilitates and coordinates physician-to-physician communication as appropriate to support the denial management process. * Communicates to appropriate teams, including business development and facility administration when clinical authorization and financial approval is complete, following standard authorization process. * Provides hospital team with needed prior authorization information on pending / new admissions. * Coordinate with managed care payor on all coverage issues and supports the LOA process as requested. * Coordinates and facilitates Concurrent Review Authorizations for patients actively in-house at a ScionHealth facility * Identifies /reviews medical record information needed from facility. * Applies appropriate clinical guidelines to concurrent review authorization process. * Review medical necessity review information provided by the case management team and communicates any additinoal questions or information requests * Acts as a liaison with the Case Management team through every stage of the concurrent review authorization process through determination. * Initiates appeals process as appropriate. * Communicates with Medical Advisors or case managers of managed care company as necessary; including during Care Coordination / Managed Care calls * Maintains a knowledge of areas of responsibility and develops and follows a program of continuing education. * Participates in continuing education/ professional development activities. * Learns and develops full knowledge of the CAAT Admission Processes and actively seeks to continuously improve them. Knowledge/Skills/Abilities/Expectations * Strong relationship building skills and a spirit to serve to ensure effective communication and service excellence. * Knowledge of regulatory standards and compliance guidelines. * Working knowledge of medical necessity justification through but not limited to non-physician review guidelines (InterQual and Milliman), Medicare and Medicaid rules, regulations, coverage guidelines, NCDs and LCDs. * Working knowledge of Medicare, Medicaid and Managed Care payment and methodology. * Extensive knowledge of clinical symptomology, related treatments and hospital utilization management. * Excellent interpersonal, verbal and written skills to communicate effectively and to obtain cooperation/collaboration from hospital leadership, as well as physicians, payors and other external customers. * Critical thinking, problem solving, and decision-making capabilities with the ability to discern, collect, organize, evaluate, and communicate pertinent clinical information with effective verbal and written skills. * Technical writing skills for appeal letters and reports. * Effective time management and prioritization skills. * Computer skills with working knowledge of Microsoft Office (Word, Excel, PowerPoint, and Outlook), word-processing and spreadsheet software. * Demonstrates good interpersonal skills when working or interacting with patients, their families and other staff members. * Conducts job responsibilities in accordance with the standards set out in the Company's Code of Business Conduct, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards. * Communicates and demonstrates a professional image/attitude for patients, families, clients, coworkers and others. * Adheres to policies and practices of ScionHealth. * Must read, write, and speak fluent English * Must have good and regular attendance. * Approximate percent of time required to travel: N/A Qualifications Education * Postsecondary non-Degree (Cert/Diploma/Program Grad) of an Accredited School of Nursing required * Associate's Degree in healthcare or related field required * Bachelor's Degree in healthcare or related field preferred * Equivalent combination of Education and/or Experience in lieu of education (3+ years in a related field) may be considered. Licenses/Certifications * Healthcare professional licensure preferred. * In lieu of licensure, 3+ years of experience in relevant field required. * Some states may require licensure or certification. Experience * 3+ years of experience in a healthcare strongly preferred. * Experience in managed care, case management, utilization review, or discharge planning a plus.

Join Our Team as a Utilization Review Manager (RN or Social Worker) Are you a compassionate nurse or social worker looking to make a real difference in behavioral health? AllHealth Network is seeking a dedicated Utilization Review Specialist to help ensure clients receive the care they need while collaborating with a team that values your expertise and commitment. Why AllHealth Network? * Work in a supportive, interdisciplinary environment that values your professional judgment * Enjoy opportunities for ongoing learning, growth, and advancement * Make a tangible impact on client outcomes and community well-being * Be part of a mission-driven organization dedicated to high-quality, client-centered care What You'll Do: * Advocate for clients by communicating clinical information to secure timely and appropriate care authorizations * Lead utilization reviews for clients in our Acute Treatment and Crisis Stabilization Units * Collaborate with nurses, social workers, case managers, and other healthcare professionals * Ensure quality care by coordinating with payers, treatment teams, and billing staff * Maintain accurate records and use your problem-solving skills to navigate challenging cases What We're Looking For: * Registered Nurse (BSN/RN) or Master's in a human services field * Clinical license (LPC, LCSW) required * Minimum 2 years' experience in behavioral health utilization management, care coordination, or case management * Strong communication, organization, and advocacy skills * Experience with insurance processes, electronic records, and multidisciplinary teamwork Ready to take your career to the next level with a team that cares as much as you do? Apply today and help us transform lives-one client at a time. $72,000 - $80,000 annually AllHealth Network also provides a 10% compensation differential for individuals who are bilingual in English and Spanish (language proficiency testing required). The base salary range represents the low and high end of the AllHealth Network hiring range for this position. Actual salaries will vary and may be above or below the range based on various factors including but not limited to experience, education, training, merit, and the ability to embody the AllHealth Network mission and values. The range listed is just one component of AllHealth Networks' total compensation package for employees. Other rewards may include short-term and long-term incentives as well as a generous benefits package detailed below.

As a Utilization Management Nurse for Post Acute care, you will be responsible for reviewing and documenting prior authorization and concurrent stay requests. You will also manage member case history in compliance with established policies and procedures, applying clinical criteria and member coverage. This role involves interfacing with members, providers, facilities, medical directors, intake staff, case managers, and other internal departments. Your attention to detail and clinical judgment will be crucial in determining the medical necessity of post-acute stays, including skilled nursing facilities, acute inpatient rehabilitation, and long-term acute care hospitals. Responsibilities + Review and document prior authorization and concurrent stay requests. + Manage and evaluate member case history in line with policies and procedures. + Interface with members, providers, facilities, medical directors, and various internal departments. + Apply clinical judgment to assess the medical necessity of post-acute stays. Essential Skills + Expertise in utilization management and utilization review. + Experience in acute care and nursing. + Proficiency in prior authorization processes. + Active, unrestricted RN license in the state of MN or WI. + Associate or bachelor's degree in nursing. + 3-5+ years of clinical experience. + Previous utilization management experience required. Additional Skills & Qualifications + Demonstrated clinical assessment skills with critical thinking and evidence-based decision-making. + Self-motivated and able to work independently and collaboratively. + Detail-oriented with strong organizational skills. + Technology-savvy with the ability to navigate multiple computer applications. Work Environment This position is remote, requiring 40 hours per week. Candidates must have a primary home address in Wisconsin or Minnesota. Internet speed tests are required, with minimum upload speeds of 5+ Mbps, download speeds of 25+ Mbps, and a ping less than 100MS. Internet speed test results must be submitted with the application. This is a 6-month contract position with the potential for extension or conversion. Job Type & Location This is a Contract position based out of Minnetonka, MN. Pay and Benefits The pay range for this position is $38.00 - $45.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: - Medical, dental & vision - Critical Illness, Accident, and Hospital - 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available - Life Insurance (Voluntary Life & AD&D for the employee and dependents) - Short and long-term disability - Health Spending Account (HSA) - Transportation benefits - Employee Assistance Program - Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type This is a fully remote position. Application Deadline This position is anticipated to close on Dec 22, 2025. About Actalent Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law. If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.

Job Description Vivo HealthStaff is searching for a Utilization Review RN for a hybrid position for a health plan in San Francisco. It is a hybrid position with 1-2 days per week on-site required. Collaborates with the physician, nurse case manager, social worker, and other members of the health care team to meet individualized patient outcomes. Performs concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers. Ensures medical necessity determinations, service authorization and concurrent denials are managed effectively and financially responsibly. Education Valid RN license in State of California Bachelor's degree in Nursing Experience Clinical experience in acute care setting Required Experience with interqual and millimen Preferred Licenses and Certifications CPR - Cardiac Pulmonary Resuscitation CPR/BLS Preferred and CCM - Certified Case Manager CCM Preferred and ACMA Preferred Knowledge, Skills, and Abilities Verbal and written communication skills. Basic computer skills. Diagnostic and problem-solving skills. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations. Actively participates in ongoing professional enrichment and educational opportunities. Collaborates with and assists the nurse case manager and social worker to meet the patients' continuing health needs in a high quality, cost effective manner. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient, LOS insurance and discharge needs. Collects quality improvement data in accordance with approved indicators. Recognizes potential problems and makes referrals to quality improvement, risk management, safety, infection control, and other departments as appropriate. Confers and collaborates routinely with the physician advisor, division chiefs, and attending physicians to resolve problems regarding acuity and level of care. Evaluates concurrent and retrospective denials for appeal opportunities. May generate appeal letters based on knowledge of clinical severity and intensity. Identifies insurance information, obtains authorization, communicates with financial counseling and assigns appropriate length of stay for admission. Implements strategies to avoid denials including potential denial notification to attending physician. Issues letter of non-coverage for Medicare or third party payers according to policies and procedures. Communicates utilization plans to case management team. Performs admission reviews and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on age specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment for services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources. Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings. Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations. Performs other duties as assigned.

$40/hour - Contract for 6 months Must reside in TX Full time remote Candidates must be based in TX. RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan. pay rate is $40/hour This position is responsible for performing initial, concurrent review activities; discharge care coordination for determining efficiency, effectiveness and quality of medical/surgical services and serving as liaison between providers and medical and network management divisions. Collects clinical and non-clinical data. Verifies eligibility. Determines benefit levels in accordance to contract guidelines. Provides information regarding utilization management requirements and operational procedures to members, providers and facilities. Registered Nurse (RN) with valid, current, unrestricted license in the state of operations. * 3 years of clinical experience in a physician office, hospital/surgical setting or health care insurance company. * Knowledge of medical terminology and procedures. * Verbal and written communication skills. PREFERRED JOB REQUIREMENTS: * Utilization management experience * MCG or InterQual experience

Who We Are Ready to create a healthier world? We are ready for you! Personify Health is on a mission to simplify and personalize the health experience to improve health and reduce costs for companies and their people. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we're shaping a healthier, more engaged future. Responsibilities Ready to Make Critical Decisions That Ensure Appropriate Patient Care? We're seeking a full time skilled RN who understands that utilization review is about ensuring patients receive the right care at the right time. As our Utilization Review Nurse, you'll use clinical expertise to assess medical necessity, support appropriate care transitions, and serve as an advocate for both quality care and cost-effective treatment options while working collaboratively with medical directors and care teams. What makes this role different ✓ Clinical decision-making: Your assessments directly impact patient care and treatment authorization decisions across multiple service lines ✓ Comprehensive scope: Review outpatient/ancillary pre-certifications, inpatient stays including mental health and substance abuse, skilled nursing, rehabilitation, and post-service reviews ✓ Care coordination focus: Work with hospital staff to ensure smooth patient transitions and optimal discharge planning to appropriate next-level care ✓ Professional autonomy: Make independent clinical judgments using MCG guidelines, internal medical policies, and NCCN while collaborating with medical directors What You'll Actually Do Assess medical necessity: Conduct professional reviews of treatment requests and plans for medical appropriateness using established clinical guidelines and evidence-based criteria. Coordinate care transitions: Partner with hospital staff to prepare patients for discharge while ensuring smooth transitions to appropriate next-level care arrangements. Navigate complex cases: Review outpatient pre-certifications, inpatient hospital stays including mental health and substance abuse treatments, skilled nursing, and rehabilitation requirements with clinical expertise. Ensure appropriate referrals: Work to top of RN license while ensuring proper referral to medical director for denial authorizations through independent review organizations (IRO). Support member wellness: Identify and refer appropriate cases to case management, wellness, chronic disease, and Nurturing Together programs while maintaining thorough documentation. Process appeals: Handle appeals for non-certification of services and complete non-certification letters when appropriate while reviewing plan documents for benefit determinations. Maintain compliance excellence: Meet productivity, quality, and turnaround time requirements while maintaining HIPAA compliance and passing external URAC and NCQA audits. Utilize clinical guidelines: Apply guidelines in appropriate hierarchy including MCG guidelines, internal medical policies, group-specific policies, and NCCN for consistent decision-making. Qualifications What You Bring to Our Mission The clinical foundation: Current RN license in United States or U.S. territory Associate's degree or diploma (Nursing program) required 1+ year clinical experience required The professional competencies: Ability to meet productivity, quality, and turnaround time requirements daily Capability to pass external audits including URAC and NCQA Commitment to maintaining HIPAA compliance per company policies and procedures Ability to complete and pass all annual testing including IRRA at 90% or higher Willingness to cross-train and provide cross-coverage as needed The clinical expertise: Strong clinical judgment for assessing medical necessity across multiple service lines Knowledge of MCG guidelines, internal medical policies, and clinical decision-making tools Ability to review plan documents and attempt to redirect providers and patients to PPO providers when beneficial Proficiency with documentation software and electronic health systems The professional qualities: Excellent communication skills with ability to explain complex medical information clearly Independent judgment combined with collaborative team approach Commitment to maintaining confidentiality and minimum requirement rules Ability to complete all required yearly training per company's expected time period Comfort navigating fast-paced, high-volume review environment while maintaining quality standards Why You'll Love It Here We believe in total rewards that actually matter-not just competitive packages, but benefits that support how you want to live and work. Your wellbeing comes first: Comprehensive medical and dental coverage through our own health solutions (yes, we use what we build!) Mental health support and wellness programs designed by experts who get it Flexible work arrangements that fit your life, not the other way around Financial security that makes sense: Retirement planning support to help you build real wealth for the future Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage Growth without limits: Professional development opportunities and clear career progression paths Mentorship from industry leaders who want to see you succeed Learning budget to invest in skills that matter to your future A culture that energizes: People Matter: Inclusive community where every voice matters and diverse perspectives drive innovation One Team One Dream: Collaborative environment where we celebrate wins together and support each other through challenges We Deliver: Mission-driven work that creates real impact on people's health and wellbeing, with clear accountability for results Grow Forward: Continuous learning mindset with team events, recognition programs, and celebrations that make work genuinely enjoyable The practical stuff: Competitive base salary that rewards your success PTO policy because rest and recharge time is non-negotiable Benefits effective day one-because you shouldn't have to wait to be taken care of Ready to create a healthier world while building the career you want? We're ready for you. No candidate will meet every single qualification listed. If your experience looks different but you think you can bring value to this role, we'd love to learn more about you. Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice. In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $30 to $38 per hour. Note that compensation may vary based on location, skills, and experience. This position is eligible for benefits. We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing. #WeAreHiring #PersonifyHealth Beware of Hiring Scams: Personify Health will never ask for payment or sensitive personal information such as social security numbers during the hiring process. All official communication will come from a verified company email address. If you receive suspicious requests or communications, please report them to **************************. All of our legitimate openings can be found on the Personify Health Career Site.

At Curana Health, we're on a mission to radically improve the health, happiness, and dignity of older adults-and we're looking for passionate people to help us do it. As a national leader in value-based care, we offer senior living communities and skilled nursing facilities a wide range of solutions (including on-site primary care services, Accountable Care Organizations, and Medicare Advantage Special Needs Plans) proven to enhance health outcomes, streamline operations, and create new financial opportunities. Founded in 2021, we've grown quickly-now serving 200,000+ seniors in 1,500+ communities across 32 states. Our team includes more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds, all working together to deliver high-quality, proactive solutions for senior living operators and those they care for. If you're looking to make a meaningful impact on the senior healthcare landscape, you're in the right place-and we look forward to working with you. For more information about our company, visit CuranaHealth.com. Summary The primary role of the Utilization Management Nurse is to review and monitor members' utilization of health care services with the goal of maintaining high quality cost-effective care. The role includes providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures. This includes providing prior authorizations, concurrent review, proactive discharge/transition planning, and high dollar claims review. There is a heavy emphasis on concurrent review and proactive transition planning, and high dollar claims review. There is a heavy emphasis on concurrent review and proactive transition planning for members in the hospital and skilled nursing facility. This is primarily a remote telephonic position with normal business day hours, with one weekend day per month coverage. This position serves as a liaison to the Plan Medical Director working closely with appeals and medical decisions. Essential Duties & Responsibilities Performs concurrent and retrospective reviews on all facility and appropriate home health services. Monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs. Evaluates and provides feedback to member's providers regarding a member's discharge plans and available covered services, including identifying alternative levels of care that may be more appropriate. As part of the hospital prior authorization process, responsible for determining “observational” vs “acute inpatient” status. Integral to the concurrent review process, actively and proactively engages with member's providers in proactive discharge/transition planning. Actively participates in the notification processes that result from the clinical utilization reviews with the facilities. Prepares CMS-compliant notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation. Maintains accurate records of all communications. Monitors utilization reports to assure compliance with reporting and turnaround times. Addresses care issues with Director of Quality and Care Management and Chief Medical Officer/Medical Director as appropriate. Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transition coordination, discharge planning and issuance of all appropriate authorizations for covered services as needed for providers and members. Coordinates identification and reporting of potential high dollar/utilization cases for appropriate reserve allocation. Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum. Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies. Responsible for the early identification of members for potential inclusion in a Chronic Care Improvement Program. Assists in the identification and reporting of Potential Quality of Care concerns. Responsible for assuring these issues are reported to the Quality Improvement Department. Work as interdisciplinary team member within Medical Management and across all departments. Other duties as assigned. Qualifications Education and Experience: Minimum 2 years clinical experience as RN, LPN/LVN required. Minimum 1-year managed care or equivalent health plan experience preferred. Demonstrated experience in health plan utilization management, facility concurrent review discharge planning, and transfer coordination required. Medicare Advantage experience preferred. Experience with InterQual or MCG authorization criteria preferred. Excellent computer skills and ability to learn new systems required. Strong attention to detail, organizational skills and interpersonal skills required. Demonstrated ability to problem solve and manage professional relationships. Certificates, Licenses and Registrations Active unrestricted Nursing license required. We're thrilled to announce that Curana Health has been named the 147 th fastest growing, privately owned company in the nation on Inc. magazine's prestigious Inc. 5000 list. Curana also ranked 16 th in the “Healthcare & Medical” industry category and 21 st in Texas. This recognition underscores Curana Health's impact in transforming senior housing by supporting operator stability and ensuring seniors receive the high-quality care they deserve.

This position is a critical part of utilization management within the emergency department setting. The role ensures that patient admissions meet medical necessity standards and that healthcare resources are used appropriately and efficiently. It combines clinical expertise, analytical skills, and communication abilities to support both patient care and organizational compliance. Responsibilities Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources Participate in telephonic discussions with emergency department physicians relative to documentation and admission status Enter clinical review information into system for transmission to insurance companies for authorization Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources Qualifications Required Current and unrestricted RN license At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 2 years utilization management experience in acute admission and concurrent reviews Intermediate level experience with InterQual and/or MCG criteria within the last two years Proficiency in medical record review in an electronic medical record (EMR) Experience in Microsoft Suite including Office and basic Excel Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs Passing score(s) on job-related pre-employment assessment(s) Preferred At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing At least 3 years utilization management experience within the hospital setting Bachelor's of Science in Nursing (BSN) Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC) Expectations Comfortable with remote work arrangements and virtual collaboration tools Physical demands include extended periods of sitting, computer use, and telephone communication Shifts Requirements & Needs: Working between the hours of 9am EST and 9pm EST either for 8-hour, 10-hour or 12-hours shifts. All Full-Time required to work 4 Holidays per year All Full-time required to work every other weekend or 4 weekend shifts per month. Additional Shifts Available: Weekend FT Available - (3, 12 hours shifts, one shift worked during a weekday) Work schedules and shift assignments are subject to change based on evolving client needs and operational demands. While we strive to provide consistent scheduling, associates may be required to adjust their availability or work different shifts. Flexibility and adaptability are essential for success in this role. Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate. Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart's sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart's third party screening provider. If you are located in a state which grants you the right to receive information on salary range, pay scale, description of benefits or other compensation for this position, please use this form to request details which you may be legally entitled. All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position. Netsmart's Job Applicant Privacy Notice may be found here.

Our vision aims to empower our clients by actively leveraging our broad range of services. With our global presence, we have career opportunities all across the world which can lead to a unique, exciting and fulfilling career path. Pick your path today! To see what career opportunities we have available, explore below to find your next career! Please be aware of employment scams where hackers pose as legitimate companies and recruiters to obtain personal information from job seekers. Please be vigilant and verify the authenticity of any job offers or communications. We will never request sensitive information such as Social Security numbers or bank details during the initial stages of the recruitment process. If you suspect fraudulent activity, contact us directly through our official channels. Stay safe and protect your personal information. Job Summary: Under general supervision of the Program Manager (PM) and reporting to the PM, the Medical Review Nurse (MRN) is responsible for the initial chart review and chart case management for medical exam/screening programs to verify that all medical information and exam components are accurate. The RN works directly with Physicians and Examinees to ensure all medical information is gathered and performs medical Quality Assurance on all charts in various process stages leading to a final determination. Salary is $66,560-$70,000. Duties and Responsibilities: • Performs medical review of incoming charts to determine if additional medical information is needed. • Collaborates with Physician(s) and other internal nursing staff members for chart review. • Performs medical Quality Assurance (QA) on all charts in various process stages. • Interfaces with Client's Medical Department as well as the on-site provider. • Contacts Examinee via telephone or email to clarify information necessary to complete the chart. • Develops a very good understanding of the specific contract's guidelines and addendums as required. • Masters the various software programs specific to the functioning of the exam program. • Implements and follows up on requests for further evaluation from the Examinee when required. • Works closely with other departments to provide accurate and quality outcomes. • Thoroughly cognizant of metrics and organizes workload to meet them. • Consistently learns and applies codified state and federal regulations specific to particular contract(s). • Serve as backup to other nurses for daily duties and assists with follow-up calls to facilities and Examinees as needed as well as other duties as assigned. • Opportunity to travel and assist on medical mobile events as either a site lead and/or RN as work or personal schedule permit. • May participate in interdepartmental project groups or task forces to integrate activities, communicate issues, obtain approvals, resolve problems, and maintain a specific level of knowledge pertaining to new developments, new task efforts, contract awards, and new policy requirements. • Supports marketing and sales objectives and efforts as requested. • Performs duties in a safe manner. Follows the corporate safety policy. Participates and supports safety meetings, training, and goals. Ensures safe operating conditions within an area of responsibility. Encourages co-workers to work safely. Identifies “close calls” and/or safety concerns to supervisory personnel. Maintains a clean and orderly work area. • Assists in the active implementation of company initiatives to ensure compliance with OSHA VPP, ISO, JCAHO, AAAHC, and other mandated regulations/standards. • May serve on the OSHA VPP, Safety, and Wellness Committees. Qualifications: • 5-7 years of relevant experience. • Fully unencumbered nursing license required. • Proficiency with computer and common office equipment, as well as with MS Office products. • Must be able to multitask, be flexible, be organized, and have excellent oral and written communication skills as well as exceptional attention to detail. Preferred Qualifications: • COHN-S and/or CAOHC certifications • Bachelor's Degree with 5 years of relevant experience • Flexibility and availability to travel and assist to support medical mobile events as either site lead and/or RN Physical Requirements and Work Conditions: • Work is normally performed in a typical interior/office work environment. • Work involves sitting and standing for prolonged periods of time. • May require bending and lifting up to 15 lbs. • Constant use of computer and common office equipment required. Acuity International is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, national origin, age, protected veteran status, or disability status. For OFCCP compliance, the taxable entity associated with this job posting is: Acuity-CHS, LLC