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Utilization review nurse jobs in Carolina, PR - 13 jobs

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Utilization Review Nurse
Nurse
Nurse Coordinator

  • Utilization Management Nurse

    Centerwell

    Utilization review nurse job in San Juan, PR

    **Become a part of our caring community and help us put health first** Healthcare isn't just about health anymore. It's about caring for family, friends, finances, and personal life goals. It's about living life fully. At Conviva, a wholly-owned subsidiary of Humana, Inc., we want to help people everywhere, including our team members, lead their best lives. We support our team members to be happier, healthier, and more productive in their professional and personal lives. We encourage our people to build relationships that inspire, support, and challenge them. We promote lifelong well-being by giving our team members fresh perspective, new insights, and exciting opportunities to enhance their careers. At Conviva, we're seeking innovative people who want to make positive changes in their lives, the lives of our patients, and the healthcare industry as a whole. Conviva Care Solutions is seeking a RN who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that focuses on excellent service to others. **Preferred Locations:** Daytona, FL, Louisville, KY, San Antonio, TX **Use your skills to make an impact** **Role Essentials** + Active Unrestricted RN license + Possession of or ability to obtain Compact Nursing License + A minimum of three years clinical RN experience; + Prior clinical experience, managed care experience, DME, Florida Medicaid **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to work independently and within a team setting + Valid driver's license and/or dependable transportation necessary + Travel for offsite Orientation 2 to 8 weeks + Travel to offsite meetings up to 6 times a year as requested + Willing to work in multiple time zones + Strong written and verbal communication skills + Attention to detail, strong computer skills including Microsoft office products + Ability to work in fast paced environment + Ability to form positive working relationships with all internal and external customers + Available for On Call weekend/holiday rotation if needed **Role Desirables** + Education: BSN or bachelor's degree in a related field + Experience with Florida Medicaid + Experience with Physical Therapy, DME, Cardiac or Orthopedic procedures + Compact License preferred + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare/Medicaid Experience a plus + Current nursing experience in Hospital, SNF, LTAC, DME or Home Health. + Bilingual **Additional Information** We offer tangible and intangible benefits such as medical, dental and vision benefits, 401k with company matching, tuition reimbursement, 3 weeks paid vacation time, paid holidays, work-life balance, growth, a positive and fun culture and much more. To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 02-18-2026 **About us** About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health - addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first - for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options *************************************************************
    $71.1k-97.8k yearly 12d ago
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  • Per Diem Flight Nurse

    Reva, Inc. 3.6company rating

    Utilization review nurse job in Carolina, PR

    Per Diem Medial - Flight Med and Avi Responsibilities include evaluation, coordination, and delivery of medical care provided to patients during transport; also is familiar with the scope of practice of the transport team members and the State rules and regulations in which the transport team operates. Works with the other transport team members to coordinate care of the patient during transport; once called, readily available/arrive at specified location, within 45 minutes before wheels. RESPONSIBILITIES: The following reflects management's definition of essential functions for this job but does not restrict the tasks that may be assigned. Management may assign or reassign duties and responsibilities to this job at any time due to reasonable accommodation or other reasons. Provides pre-hospital advanced life support care from initial contact until patient care is relinquished to the receiving medical facility Maintain thorough electronic charting of patient care. Attends pre-mission briefings and mission debriefing and completes necessary documentation Complies with safety standards to assure safety of self, medical personnel, patient, and equipment prior to takeoff. Must be familiar with scope of practice of the transport team and the State rules and regulations in which the transport team operates. Requirements: Minimum of 3 years of ICU/ED/Trauma experience within the last 5 years Previous flight experience preferred. Flight experience can be substituted year for year for the ICU/ED/Trauma requirement. RN license as appropriate to assigned location Basic Life Support (BLS) certification Advanced Cardiac Life Support (ACLS) Pediatric Advanced Life Support (PALS) Neonatal Resuscitation Program (NRP) certification Pre-hospital Trauma Life Support (PHTLS) or Basic Trauma Life Support (BTLS) certification preferred but not required. Certified Emergency Nurse (CEN), Critical Care Nurse (CCRN) or Flight Registered Nurse (CFRN) strongly recommended. Completing quarterly requirements to maintain active flight status to include: completion of intubations quarterly, attendance at Roundtables. Completing annual requirements to maintain active flight status to include: Advanced Airway course, Mock Codes, AvStar program, safety and infection control, aircraft / personnel security briefing, equipment and supplies competency / currency validation, medical screening update including copy of TB or equivalent, ICU and trauma competencies, wellness form, EMS Rules and Regulations, and Haz-mat recognition and response. Evaluation is contingent upon completion of these items prior to evaluation. Current Passport required Ability to work varied shifts and cover fixed wing air ambulance call shifts Drug screening and a background investigation required. Physical Requirements: While performing the duties of this job, the employee is frequently required to do the following: Walk and stand for prolonged periods Lift and/or move up to 50 pounds Transfer/position patients of all ages and physical conditions Collect, interpret, and/or analyze diagnostic data Utilize visual, auditory, verbal, and olfactory processes required to assess, monitor, and care for patients Interpret complex laws, regulations, and/or policies Coordinate multiple tasks simultaneously Understand and respond to a diverse population Work in a high stress environment while remaining calm composure Work various shifts and schedules Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Frequent exposure to blood-borne and airborne pathogens or infectious materials Long transport times in the confined space of the aircraft. Exposure to dynamic cultural diversity Locations: San Juan, PR, Carollna, PR, Fort Lauderdale, FL, Schenectady, NY ABOUT REVA: In the medical transport industry, urgency, reliability, and experience are absolutely critical. We have completed over 30,000 flights in 70 countries. From marooned hikers to critically ill patients, REVA provides medical transport service 24 hours a day, 7 days a week, worldwide. When patients need care that cannot be provided during normal travel or in the region they are currently in, they call REVA. REVA's reach is worldwide. Four bases of operation within North America, the Caribbean, and Europe provide points of departure convenient to even the most distant locales. Our 13 dedicated ICU configured Jets, more than 200 air-ambulance professionals, and Global Alliance with industry partners give us a global profile. If it's on the Earth, it's on our radar. REVA is an equal opportunity employer that celebrates employees and applicants of all identities, backgrounds, abilities, and perspectives. We foster a welcoming work environment that supports diversity and inclusion, and we reject discrimination or harassment of any individual. If you are a person with a disability and require assistance with any part of the application process, please let us know. All employment decisions are made on the basis of qualifications, merit, and business need.
    $35k-49k yearly est. Auto-Apply 60d+ ago

  • Nursing Success Coordinator

    NUC University

    Utilization review nurse job in San Juan, PR

    Job Description A Nursing Success Coordinator who uses Assessment Technologies Institute (ATI) and the simulations of Nursing, resources serves as a dedicated academic support professional within a nursing program, focused on improving student performance, retention, and NCLEX success rates. This role involves acting as a liaison between students, faculty, and ATI, Evolve, Sherpath, vSim and others simulators programs. Essential Duties and Responsibilities: Student Remediation and Support: Establishes plans of action for students who fail exams or struggle academically, providing one-on-one or group tutoring, workshops, and study habit coaching. They guide students through online modules and tutorials, such as the Launch academic readiness program, to build foundational knowledge and essential nursing skills. ATI Integration and Management: Ensures the smooth operation and full integration of ATI, Evolve, Sherpath, vSim and others simulators programs resources across all program levels. This includes scheduling and setting up testing, managing student accounts, and assisting faculty in using ATI, Evolve, Sherpath, vSim and others simulators programs materials in both classroom and clinical settings. Data Analysis and Intervention: Analyzes data from proctored assessments, practice exams, and student time in tutorials to identify individual and cohort weaknesses and trends. This data-driven approach allows for personalized study plans and early intervention strategies. Faculty Liaison and Training: Serves as a campus "ATI champion," Evolve, Sherpath, vSim and others simulators programs. Ensuring faculty training is completed and best practices for using all products are reinforced throughout the program. They also serve as the main point of contact with ATI, Evolve, Sherpath, vSim and others simulators programs. company representatives. NCLEX Preparation: Utilizes ATI's, Evolve, Sherpath, vSim and others simulators programs comprehensive predictor exams and other resources to track student progress and predict NCLEX success, providing targeted support to ensure students are practice-ready upon graduation. Supervisory Responsibilities: This role does not involve supervision of other employees but may provide guidance and support to students and faculty as needed. Qualifications/Education: Master's degree in Nursing (MSN) with Role in Education highly desirable. Current specialist nurse license. Relevant nursing experience, typically several years, is expected. Familiarity and expertise with the ATI, Evolve, Sherpath, vSim and others simulators programs and learning platforms are essential skills for this role. Strong interpersonal, communication, and data management skills are necessary to collaborate with faculty, advise students, and manage program data effectively Proficiency and familiarity with educational platforms and simulation programs such as ATI, Evolve, Sherpath, vSim, and other learning management or simulation tools are essential. Strong interpersonal, communication, and data management skills are required to effectively collaborate with faculty, advice and support students, and manage academic and program-related data. Competencies: Technical Competencies Proficiency in Learning Management Systems (LMS) such as Canvas and their integration with ATI, Evolve, Sherpath, vSim, and other learning management or simulation tools are essential. Competence in digital tools such as Microsoft Teams, Words, Excel, among others. Ability to analyze student performance data and apply findings to continuous improvement initiatives. Knowledge of simulation-based learning methodologies and assessment tools. Core Competencies Strong analytical, organizational, and problem-solving skills. Excellent written and verbal communication abilities. Leadership and teamwork skills with a focus on collaboration and faculty support. Ability to train and mentor faculty and students in the effective use of technological platforms. Commitment to academic excellence, innovation, and quality improvement. High attention to detail, confidentiality, and data integrity. Capacity to manage multiple priorities in a fast-paced academic environment. Language Skills: Ability to express him or herself correctly, precisely, and effectively, orally and in writing. Command of English and Spanish. Mathematical Skills: Ability to make mathematical and deductive reasoning problem solving.+ Technological Skills: Computer skills including practical experience in Microsoft Word, Power Point, Outlook with advance skills in Microsoft Excel. Reasoning Ability: Can identify problems and present solutions. Physical Demands: While performing the duties of the position, physical effort is required (hands and feet). Work Environment: The work environment is dynamic and active. Work will be in an office with different tasks.
    $44k-51k yearly est. 15d ago

  • Appeals Nurse

    Evolent 4.6company rating

    Utilization review nurse job in San Juan, PR

    **Your Future Evolves Here** Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. **What You'll Be Doing:** The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures while complying with timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the Clients and Members we serve. **Collaboration Opportunities:** The Specialty Appeal nurses work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators who set up the appeal, Physicians and other Clinicians who review the appeal, and managers for direction and leadership. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats, and monthly communication on team metrics and accomplishments. **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures. + Documents communications with medical office staff and/or MD provider as required. + Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews. + Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan's required timeframes. + Refers cases to appropriate internal reviewers according to the business needs of the particular health plan. + Reviews requests for Urgent appeals compared to expedited criteria for downgrade to Standard processing, documenting accordingly. + Works closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals. + Other duties as assigned. **Qualifications Required and Preferred:** + 1-3 years' experience and as an RN - **Required** + Minimum of 5 years in Utilization Management, health care Appeals, compliance and/or grievances/complaints in a quality improvement environment- **Required** + Able to work in a rotation to work 10:30am to 7pm CST (which includes 30-minute unpaid lunch break) 3 days/week, to meet the business needs of nurses providing coverage until 7:00pm CST. - **Required** + Must be able to exercise independent and sound judgment in clinical decision making. - **Preferred** + Able to navigate through internal and external computer systems. Working knowledge of Microsoft Office Product Suit - **Preferred** + Strong organizational and effective time management skills; demonstrated ability to manage multiple priorities. - **Preferred** + Outstanding interpersonal and negotiation skills to effectively establish positive relationships both internally and externally, including strong written and verbal communication skills. - **Preferred** To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration. **Technical Requirements:** We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations. **Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.** **If you need reasonable accommodation to access the information provided on this website, please contact** ************************** **for further assistance.** The expected base salary/wage range for this position is $37- $42/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!
    $37-42 hourly 60d+ ago

  • Nursing Success Coordinator

    National College of Business & Technology 3.9company rating

    Utilization review nurse job in San Juan, PR

    A Nursing Success Coordinator who uses Assessment Technologies Institute (ATI) and the simulations of Nursing, resources serves as a dedicated academic support professional within a nursing program, focused on improving student performance, retention, and NCLEX success rates. This role involves acting as a liaison between students, faculty, and ATI, Evolve, Sherpath, vSim and others simulators programs. Essential Duties and Responsibilities: Student Remediation and Support: Establishes plans of action for students who fail exams or struggle academically, providing one-on-one or group tutoring, workshops, and study habit coaching. They guide students through online modules and tutorials, such as the Launch academic readiness program, to build foundational knowledge and essential nursing skills. ATI Integration and Management: Ensures the smooth operation and full integration of ATI, Evolve, Sherpath, vSim and others simulators programs resources across all program levels. This includes scheduling and setting up testing, managing student accounts, and assisting faculty in using ATI, Evolve, Sherpath, vSim and others simulators programs materials in both classroom and clinical settings. Data Analysis and Intervention: Analyzes data from proctored assessments, practice exams, and student time in tutorials to identify individual and cohort weaknesses and trends. This data-driven approach allows for personalized study plans and early intervention strategies. Faculty Liaison and Training: Serves as a campus "ATI champion," Evolve, Sherpath, vSim and others simulators programs. Ensuring faculty training is completed and best practices for using all products are reinforced throughout the program. They also serve as the main point of contact with ATI, Evolve, Sherpath, vSim and others simulators programs. company representatives. NCLEX Preparation: Utilizes ATI's, Evolve, Sherpath, vSim and others simulators programs comprehensive predictor exams and other resources to track student progress and predict NCLEX success, providing targeted support to ensure students are practice-ready upon graduation. Supervisory Responsibilities: This role does not involve supervision of other employees but may provide guidance and support to students and faculty as needed. Qualifications/Education: Master's degree in Nursing (MSN) with Role in Education highly desirable. Current specialist nurse license. Relevant nursing experience, typically several years, is expected. Familiarity and expertise with the ATI, Evolve, Sherpath, vSim and others simulators programs and learning platforms are essential skills for this role. Strong interpersonal, communication, and data management skills are necessary to collaborate with faculty, advise students, and manage program data effectively Proficiency and familiarity with educational platforms and simulation programs such as ATI, Evolve, Sherpath, vSim, and other learning management or simulation tools are essential. Strong interpersonal, communication, and data management skills are required to effectively collaborate with faculty, advice and support students, and manage academic and program-related data. Competencies: Technical Competencies Proficiency in Learning Management Systems (LMS) such as Canvas and their integration with ATI, Evolve, Sherpath, vSim, and other learning management or simulation tools are essential. Competence in digital tools such as Microsoft Teams, Words, Excel, among others. Ability to analyze student performance data and apply findings to continuous improvement initiatives. Knowledge of simulation-based learning methodologies and assessment tools. Core Competencies Strong analytical, organizational, and problem-solving skills. Excellent written and verbal communication abilities. Leadership and teamwork skills with a focus on collaboration and faculty support. Ability to train and mentor faculty and students in the effective use of technological platforms. Commitment to academic excellence, innovation, and quality improvement. High attention to detail, confidentiality, and data integrity. Capacity to manage multiple priorities in a fast-paced academic environment. Language Skills: Ability to express him or herself correctly, precisely, and effectively, orally and in writing. Command of English and Spanish. Mathematical Skills: Ability to make mathematical and deductive reasoning problem solving.+ Technological Skills: Computer skills including practical experience in Microsoft Word, Power Point, Outlook with advance skills in Microsoft Excel. Reasoning Ability: Can identify problems and present solutions. Physical Demands: While performing the duties of the position, physical effort is required (hands and feet). Work Environment: The work environment is dynamic and active. Work will be in an office with different tasks.
    $39k-44k yearly est. Auto-Apply 14d ago

  • Admitting Nurse

    Alivia Health

    Utilization review nurse job in Guaynabo, PR

    The Infusion Admitting / Evaluating Nurse is responsible for providing specialized infusion therapy care in the patient's home, performing clinical evaluations to determine eligibility and continuity of treatment. Administers intravenous therapies, educates the patient and their family, and documents in accordance with clinical, regulatory, and accreditation standards (ACHC, CMS, and Puerto Rico Department of Health). The admitting nurse must foster Alivia's values, support the vision of the infusion department, and actively contribute towards the unit's success. Responsibilities include, but are not limited to the following: Conduct initial clinical assessments at home to determine the feasibility and safety of infusion treatment. Admit patients within 24 hours of receiving the referral. In accordance with regulatory and accreditation standards. Coordinate medication reconciliation and develop the initial care plan in conjunction with the prescribing physician and multidisciplinary team. Monitor the patient's response to treatment and document clinical findings in the electronic system. Educate the patient and family about treatment, devices, infection control, warning signs, and patient rights and responsibilities. Obtain and document the patient's informed consent in the medical record. Identify and report adverse events, incidents, complaints, deviations, or clinical risks to the quality and compliance committee in a timely manner. Required: Bachelor's degree in nursing from an accredited university. Current nursing license in Puerto Rico. Participation in continuing education and documented annual clinical competencies. Valid driver's license in Puerto Rico and availability of a motor vehicle. Minimum of 2 years of experience in home health, infusion, or acute care services. Preferably in a home setting. Knowledge of infusion pumps, central and peripheral catheters. ***Equal Opportunity Employer M/F/V/D***
    $32k-49k yearly est. Auto-Apply 60d+ ago

  • Nurse Reviewer I (Nclex)

    Paragoncommunity

    Utilization review nurse job in H Rivera Coln, PR

    Nurse Reviewer I Location: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. This position will be based in either San Juan, PR or Mayaguez, PR. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. A proud member of the Elevance Health family of companies, Carelon Global Solutions, formerly Legato Health Technologies is a managed service delivery organization, providing information technology and business operations services for health plans. Schedule: This position will work an 8-hour shift Monday through Friday with a work shift scheduled between the operational hours of 8:00 am - 6:00 pm (AST). Additional hours, including weekends or holidays, may be required based on operational needs. The Nurse Reviewer I is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews by utilizing appropriate policies, clinical and department guidelines. How You Will Make an Impact: Primary duties may include, but are not limited to: Conduct clinical medication reviews requiring advanced nursing assessment and critical thinking. Analyze claims and medication history to identify risks and recommend safe, evidence-based alternatives. Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network. Notifies ordering physician or rendering service provider office of the preauthorization determination decision. Follows-up to obtain additional clinical information. Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics. Minimum Requirements: Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities, and Experiences: NCLEX Certification or current unrestricted RN license from one of the 50 states of the United States and current Puerto Rico Nursing Board license. BA/BS degree preferred. Advanced understanding of medication indications and side effects is strongly preferred. Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred. Previous utilization and/or quality management and/or call center experience preferred. Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
    $43k-48k yearly est. Auto-Apply 5d ago

  • Nurse Reviewer I (Nclex)

    Elevance Health

    Utilization review nurse job in San Juan, PR

    Nurse Reviewer I Location: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. This position will be based in either San Juan, PR or Mayaguez, PR. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. A proud member of the Elevance Health family of companies, Carelon Global Solutions, formerly Legato Health Technologies is a managed service delivery organization, providing information technology and business operations services for health plans. Schedule: This position will work an 8-hour shift Monday through Friday with a work shift scheduled between the operational hours of 8:00 am - 6:00 pm (AST). Additional hours, including weekends or holidays, may be required based on operational needs. The Nurse Reviewer I is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews by utilizing appropriate policies, clinical and department guidelines. How You Will Make an Impact: Primary duties may include, but are not limited to: * Conduct clinical medication reviews requiring advanced nursing assessment and critical thinking. * Analyze claims and medication history to identify risks and recommend safe, evidence-based alternatives. * Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network. * Notifies ordering physician or rendering service provider office of the preauthorization determination decision. * Follows-up to obtain additional clinical information. * Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics. Minimum Requirements: * Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background. * Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities, and Experiences: * NCLEX Certification or current unrestricted RN license from one of the 50 states of the United States and current Puerto Rico Nursing Board license. * BA/BS degree preferred. * Advanced understanding of medication indications and side effects is strongly preferred. * Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred. * Previous utilization and/or quality management and/or call center experience preferred. * Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
    $43k-48k yearly est. 4d ago

  • PT Nurse (48170)

    Westcare 4.3company rating

    Utilization review nurse job in Caguas, PR

    Functions as primary intensive outpatient counselor for women with substance abuse or co-occurring disorders. Essential Job Functions: Maintains and demonstrates a comprehensive understanding of the concepts of a patient's care and supervision. Responsible for supervising each medical and general health history of all clients. Ensure that each client receives the best possible care. Oversees the administration of medications according to policies and procedures, controlling schedules and doses and ensuring that they are administered to clients when necessary. Verify, keep up to date and sign the medication record of the clients. Help perform regular exams and routine checkups on clients. Observe, understand, and manage health problems peculiar to the clients served. Assist the contracted physician, with basic medical examinations and the administration of prescribed treatments. Help maintain a record for your clients to have accurate records of the client's medical history, treatment plan, and progress.Participates in the creation and implementation of protocols for the treatment of the client and documents the medical record according to the treatment plan. Help perform prescribed tests on your clients, such as vital signs, blood pressure, temperature, breathing, pulse, and blood sugar checks. Responsible for ensuring that clients receive all appropriate services Provide help so that clients feel that their physical, social and affective needs are resolved. You must be an understanding, loving person with positive energy. Completes required documentation, including progress notes, behavioral observations, incident reports, and other appropriate documentation and within set deadlines. Reports and/or documents clients' observations and contributes to treatment decisions. Other assigned tasks focused on the client. Qualifications Essential Qualifications: Certifications/Licenses: Current professional Nurse license issued by the Nursing Examining Board of Puerto Rico Education: Bachelors Degree in Nursing Experience in substance abuse field is preferred. Experience and Competencies: Experience in substance abuse field is preferred. Working Conditions: Work is primarily performed in an office or residential treatment setting; and Some outdoor activities may be required. Essential Physical and Mental Demands of the Job The employee must be able to perform the following essential duties and activities with or without accommodation: Physical Demands: Requires mobility and physical activity. Having an adequate range of body motion and mobility, to work in the office environment including standing and walking (even and uneven surfaces) to interact with co-workers in the office environment, sitting for extended periods of time, bending, twisting, reaching, balancing, occasional lifting and carrying of up to 30 pounds. Constant use of a computer and telephone system is required, which includes coordination of eye and hand, and fine manipulation by the hands (typing, writing, and working with files). Requires the ability to operate a motor vehicle. Requires talking: Expressing or exchanging ideas by means of the spoken word. Talking is required to impart oral information to employees, clients, and the public and in those activities in which the employee is required to convey detailed or important spoken instructions to others accurately, loudly, or quickly. Requires hearing: Hearing is required to receive and communicate detailed information through oral communication. Requires seeing: Clarity of vision at 20 inches or less as well as vision adequate for driving a motor vehicle. This factor is required to complete paperwork for many of the employee's essential job functions and when driving a motor vehicle. The normal work routine may involve exposure to human blood, body fluids or tissues. Job duties may include performing or assisting in emergency medical care or first aid. Mental Demands: Requires the ability to collect and analyze complex numerical and written data and verbal information to reach logical conclusions. Requires the ability to work and cooperate with clients, co-workers, managers, the public and employees at all levels to exchange ideas, information, instructions, and opinions. Requires the ability to work under stress and in emotionally charged settings. The ability to defend oneself and clients in mentally/verbally abusive situations using approved mental/verbal de-escalation techniques.
    $35k-49k yearly est. 16d ago

  • HP3 Nurse

    APS Health Care Pr 4.1company rating

    Utilization review nurse job in Naranjito, PR

    The Health Professional 3/RN provides health and wellbeing services as part of the clinic's multidisciplinary team. This key individual promotes and restores patients' health in collaboration with physicians and multidisciplinary team members. The main responsibility will be integrate de psychological and physical areas of our patient. Essential Functions: Completes initial interview with the patient; reviews and analyzes data collected in order to identify specific needs, strengths and limitations. Recognizes and carefully manages urgent patients, as well as implements the necessary actions in case of emergency or hospitalization, based on Law 408 and the company's procedures. Coordinates patient transfers to the appropriate health care setting. Develops a patient treatment plan with a multidisciplinary focus, while promoting patient participation in treatment strategies. Discusses clinical cases and procedures with other team members in order to collect important information for treatment strategy elaboration. Assures that all patients at the clinic triage have completed an arterial pressure, pulse, and vital signs check. Collaborates in urine test collection in order to determine drug abuse/use as needed. Controls and administers the Drug Deposit and evaluates patients for the clinics depot. Contacts and monitors the attendance of depot patients. Keeps drug inventory and temperature monitoring in accordance with Pharmacy regulations. Maintains communication with patient's family members and provides supplementary treatment as needed. Provides individual or group advice to patients and family members about use and abuse of medication, or in any topic needed for treatment. Documents patient intervention and properly stores all suitable forms in the patient's file. Maintains registry of all patient care medication. Identifies potential treatment side effects and reports findings do Clinic Administrator, Physician and or Pharmacy Department. Coordinates and performs medical communication with patient Physical PCP ad necessary. Transfers patients to other facilities when needed. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable. In addition, all other duties assigned by the manager and/or supervisor. Education: Bachelor's degree in Nursing required Must have current, unrestricted PR License to practice in Puerto Rico territory, with current Professional Nursing College Membership. Experience: Minimum 2+ years of experience in the mental health and or/nursing field. Knowledge: Knowledge of medication, drug interactions, side effects, incompatibilities and all issued related to proper treatment. Knowledge of diagnosis and pharmacology. Knowledge of mental health regulations and related laws. Must be able to prioritize and target interventions, consistent with state licensure scope of practice requirements designed to support long-term behavioral change. Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum. Knowledge regarding nursing process and correct administration guidelines.
    $40k-50k yearly est. Auto-Apply 12d ago

  • Nurse Reviewer I (Nclex)

    Elevance Health

    Utilization review nurse job in Mayagez, PR

    Nurse Reviewer I Location: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. This position will be based in either San Juan, PR or Mayaguez, PR. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. A proud member of the Elevance Health family of companies, Carelon Global Solutions, formerly Legato Health Technologies is a managed service delivery organization, providing information technology and business operations services for health plans. Schedule: This position will work an 8-hour shift Monday through Friday with a work shift scheduled between the operational hours of 8:00 am - 6:00 pm (AST). Additional hours, including weekends or holidays, may be required based on operational needs. The Nurse Reviewer I is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews by utilizing appropriate policies, clinical and department guidelines. How You Will Make an Impact: Primary duties may include, but are not limited to: * Conduct clinical medication reviews requiring advanced nursing assessment and critical thinking. * Analyze claims and medication history to identify risks and recommend safe, evidence-based alternatives. * Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network. * Notifies ordering physician or rendering service provider office of the preauthorization determination decision. * Follows-up to obtain additional clinical information. * Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics. Minimum Requirements: * Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background. * Current unrestricted RN license in applicable state(s) required. Preferred Skills, Capabilities, and Experiences: * NCLEX Certification or current unrestricted RN license from one of the 50 states of the United States and current Puerto Rico Nursing Board license. * BA/BS degree preferred. * Advanced understanding of medication indications and side effects is strongly preferred. * Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred. * Previous utilization and/or quality management and/or call center experience preferred. * Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
    $43k-48k yearly est. 4d ago

  • Admitting Nurse

    Alivia Health

    Utilization review nurse job in Guaynabo, PR

    Job Description The Infusion Admitting / Evaluating Nurse is responsible for providing specialized infusion therapy care in the patient's home, performing clinical evaluations to determine eligibility and continuity of treatment. Administers intravenous therapies, educates the patient and their family, and documents in accordance with clinical, regulatory, and accreditation standards (ACHC, CMS, and Puerto Rico Department of Health). The admitting nurse must foster Alivia's values, support the vision of the infusion department, and actively contribute towards the unit's success. Responsibilities include, but are not limited to the following: Conduct initial clinical assessments at home to determine the feasibility and safety of infusion treatment. Admit patients within 24 hours of receiving the referral. In accordance with regulatory and accreditation standards. Coordinate medication reconciliation and develop the initial care plan in conjunction with the prescribing physician and multidisciplinary team. Monitor the patient's response to treatment and document clinical findings in the electronic system. Educate the patient and family about treatment, devices, infection control, warning signs, and patient rights and responsibilities. Obtain and document the patient's informed consent in the medical record. Identify and report adverse events, incidents, complaints, deviations, or clinical risks to the quality and compliance committee in a timely manner. Required: Bachelor's degree in nursing from an accredited university. Current nursing license in Puerto Rico. Participation in continuing education and documented annual clinical competencies. Valid driver's license in Puerto Rico and availability of a motor vehicle. Minimum of 2 years of experience in home health, infusion, or acute care services. Preferably in a home setting. Knowledge of infusion pumps, central and peripheral catheters. ***Equal Opportunity Employer M/F/V/D***
    $32k-49k yearly est. 20d ago

  • Admitting Nurse

    Alivia Health

    Utilization review nurse job in Ponce, PR

    Job Description The Infusion Admitting / Evaluating Nurse is responsible for providing specialized infusion therapy care in the patient's home, performing clinical evaluations to determine eligibility and continuity of treatment. Administers intravenous therapies, educates the patient and their family, and documents in accordance with clinical, regulatory, and accreditation standards (ACHC, CMS, and Puerto Rico Department of Health). The admitting nurse must foster Alivia's values, support the vision of the infusion department, and actively contribute towards the unit's success. Responsibilities include, but are not limited to the following: Conduct initial clinical assessments at home to determine the feasibility and safety of infusion treatment. Admit patients within 24 hours of receiving the referral. In accordance with regulatory and accreditation standards. Coordinate medication reconciliation and develop the initial care plan in conjunction with the prescribing physician and multidisciplinary team. Monitor the patient's response to treatment and document clinical findings in the electronic system. Educate the patient and family about treatment, devices, infection control, warning signs, and patient rights and responsibilities. Obtain and document the patient's informed consent in the medical record. Identify and report adverse events, incidents, complaints, deviations, or clinical risks to the quality and compliance committee in a timely manner. Required: Bachelor's degree in nursing from an accredited university. Current nursing license in Puerto Rico. Participation in continuing education and documented annual clinical competencies. Valid driver's license in Puerto Rico and availability of a motor vehicle. Minimum of 2 years of experience in home health, infusion, or acute care services. Preferably in a home setting. Knowledge of infusion pumps, central and peripheral catheters. ***Equal Opportunity Employer M/F/V/D***
    $32k-49k yearly est. 20d ago

Learn more about utilization review nurse jobs

How much does a utilization review nurse earn in Carolina, PR?

The average utilization review nurse in Carolina, PR earns between $41,000 and $51,000 annually. This compares to the national average utilization review nurse range of $47,000 to $89,000.

Average utilization review nurse salary in Carolina, PR

$46,000

What are the biggest employers of Utilization Review Nurses in Carolina, PR?

The biggest employers of Utilization Review Nurses in Carolina, PR are:
  1. Centerwell
  2. Elevance Health
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