- University of Washington (Seattle, WA)
- …least one of the following: certified healthcare chart auditor, certified professional in utilization review (or utilization management or healthcare ... Medicine's Patient Financial Services Department** has an outstanding opportunity for a **Clinical Appeals and Disputes Nurse .** **WORK SCHEDULE** + 100% FTE +… more
- Evolent (Springfield, IL)
- …and accomplishments. **What You Will Be Doing:** + Practices and maintains the principles of utilization management and appeals management by adhering to ... and as an RN - **Required** + Minimum of 5 years in Utilization Management , health care Appeals , compliance and/or grievances/complaints in a quality… more
- Molina Healthcare (WI)
- …be required. * Serves as a clinical resource for utilization management , chief medical officer, physicians, and member/provider inquiries/ appeals . * Provides ... JOB DESCRIPTION **Job Summary** The RN Clinical Appeals Nurse provides support for internal...officer on denial decisions. * Resolves escalated complaints regarding utilization management and long-term services and supports… more
- CVS Health (Columbus, OH)
- …with heart, each and every day. **Position Summary** CVS Aetna is seeking a dedicated ** Appeals Nurse Consultant** to join our remote team. In this role, you ... state of residence. + 3+ years clinical experience. **Preferred Qualifications** + Appeals , Managed Care, or Utilization Review experience. + Pre Certification… more
- BronxCare Health System (Bronx, NY)
- …assist the department's leadership develop strategies for denial prevention, improved utilization management , documentation of medical necessity and identify ... avoidable day and barriers to discharge processes pertaining to utilization management . - Liaisons and coordinates with...On the job or formal training in certified case management , denial and appeals management … more
- LA Care Health Plan (Los Angeles, CA)
- …least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting, At least 2 years in ... Lead Customer Solution Center Appeals and Grievances RN Job Category: Clinical Department:...position will mentor, coach, and may provide feedback to management on performance of staff. Ensure team effectiveness and… more
- McLaren Health Care (Mount Pleasant, MI)
- …education sessions to maintain competency and knowledge of regulations in denials, utilization management , care management , clinical documentation, and ... . Provides support to both internal and external customers for denial/ appeals activities and audits. Assists with monitoring and auditing activities, reviews… more
- Nuvance Health (Danbury, CT)
- …in Milliman and InterQual Guidelines required * Minimum of 2-3 years experience as Utilization Management Nurse in an acute care setting required, minimum ... *Description* *Summary:* The purpose of the Denial Prevention Nurse is to ensure that all patient admissions...the interdisciplinary care team * Current working knowledge of utilization management , performance improvement and managed care… more
- Rochester Regional Health (Rochester, NY)
- …class as needed. Responsibilities include concurrent (as needed) and retrospective reviews. The Utilization Management Nurse will act as a resource on ... Job Title: Registered Nurse I Department: Utilization Management...UM review findings, initiate and 1st, 2nd, and/or arbitration appeals as needed. Document in all areas that an… more
- Cognizant (Salem, OR)
- …background - Registered Nurse (RN) + 2-3 years combined clinical and/or utilization management experience with managed health care plan + 3 years' experience ... Time **Location:** Remote **About the role** As a Registered Nurse you will make an impact by performing advanced...care revenue cycle or clinic operations + Experience in utilization management to include Clinical Appeals… more
- Integra Partners (Troy, MI)
- …experienced in the managed care payor environment to perform pre-service and post-service utilization reviews and appeals for DMEPOS. This individual will play a ... Medical Director to perform benefit and medical necessity reviews and appeals within an NCQA-compliant UM program. Salary: $60,000.00/annual JOB QUALIFICATIONS:… more
- McLaren Health Care (Port Huron, MI)
- …as Assigned:** 1. Performs a variety of concurrent and retrospective utilization management -related reviews and functions to ensure that appropriate ... or order entry for timeliness, appropriateness and completeness as pertains to the utilization management process including level of care, medical necessity, and… more
- State of Connecticut, Department of Administrative Services (East Hartford, CT)
- Utilization Review Nurse Coordinator (40 Hour) Office/On-site Recruitment # 251212-5613FP-001 Location East Hartford, CT Date Opened 12/16/2025 12:00:00 AM ... to learn more about joining our team as a Utilization Review Nurse Coordinator! The State of...types of case reviews for quality and appropriate medical management , cost containment, peer review and rehabilitation; + Implement… more
- Minnesota Visiting Nurse Agency (Minneapolis, MN)
- **12/2/2025 - REVISED FTE *_SUMMARY:_* We are currently seeking a*Staff Nurse *to join our Utilization Management department for the/Emergency Department / ... *Assessment:* * Collects, reviews, and documents clinical data relevant to utilization management , including patient status, treatment plans, and healthcare… more
- UNC Health Care (Kinston, NC)
- …applied clinical experience as a Registered Nurse required. + 2 years utilization review, care management , or compliance experience preferred. + Minimum 1 ... support the clinical documentation specialists and Patient Financial Services. Supports the Utilization Review Nurse team when necessary by applying established… more
- Sanford Health (Rapid City, SD)
- …providing direct supervision of all departmental staff. Maintains a standardization of utilization management process to ensure all policies and procedures are ... Full time **Weekly Hours:** 40.00 **Department Details** Join our team as a Utilization Review and Case Management Manager and lead a high-impact, data-driven… more
- Huron Consulting Group (Chicago, IL)
- …the expert you are now and create your future. The Manager of Utilization Management is responsible for planning, organizing, developing, and directing ... Review Plan and the overall operation of the Utilization Management Department in accordance with federal,...Performance Tracking and Improvement: Provides analysis and reports of utilization , denials, and appeals KPIs, trends, patterns,… more
- University of Utah Health (Salt Lake City, UT)
- …communication skills. + Demonstrated knowledge of payers, payer systems, cost effective utilization management and InterQual criteria. + The ability to ... and as a team member. **Qualifications** **Qualifications** **Required** + One year Utilization Review or Case Management experience. **Licenses Required** +… more
- US Tech Solutions (Columbia, SC)
- …team works with multiple applications to process authorization and appeals requests using Medicare criteria. **Responsibilities:** + Reviews and evaluates ... established clinical criteria to service requests or provides health management program interventions. Utilizes clinical proficiency and claims knowledge/analysis to… more
- Actalent (Rancho Cordova, CA)
- Utilization Review Nurse About the Role...2-3 years of clinical experience in prior authorization, case management , or utilization management + ... We're looking for a Utilization Review (UR) Nurse to join our team and support high‑quality, cost‑effective patient care from a fully remote environment. This… more