- Actalent (Minnetonka, MN)
- Utilization Management Nurse Job...or bachelor's degree in nursing. + 3-5+ years of clinical experience. + Previous utilization management ... Description As a Utilization Management Nurse for Post Acute care, you will be responsible...history in compliance with established policies and procedures, applying clinical criteria and member coverage. This role involves interfacing… 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 / ... utilization and controlling costs./**/ *Assessment:* * Collects, reviews, and documents clinical data relevant to utilization management , including… more
- CenterWell (St. Paul, MN)
- …RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to ... Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare… more
- Minnesota Visiting Nurse Agency (Minneapolis, MN)
- …Oversees daily operations, which include supervising staff performing utilization management activities. The goal is to achieve clinical , financial, and ... utilization goals through effective management , communication, and role modeling. Functions as the internal...fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status… more
- Evolent (St. Paul, MN)
- … Reviewer, Nurse , you will routinely interact with leadership and management staff, other CR's ( Clinical Reviewers), providers, office staff and Field ... culture. **What You'll Be Doing:** Job Description As a Clinical Reviewer, Nurse , you will be a..., you will be a key member of the utilization management team. We can offer you… more
- Evolent (St. Paul, MN)
- …for the mission. Stay for the culture. **What You'll Be Doing:** The Clinical Review Nurse is responsible for performing precertification and prior approvals. ... physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care… more
- Fresenius Medical Center (Hastings, MN)
- **About this role:** As a Clinical Manager with Fresenius Medical Care, you will ensure that quality patient care is delivered while maintaining clinical ... or chronic kidney disease. **Training and advancement:** You will enter our Clinical Leadership Program that creates and supports a culture of continuous learning… more
- Fairview Health Services (Maplewood, MN)
- …for services provided + Completes the requirements of various payers and utilization management reviewers to obtain authorization for treatment. Demonstrates the ... as an interdisciplinary team member. Responsible, as assigned, for the management of caseload. **Job Expectations:** Works collaboratively with the physician and… more
- Humana (St. Paul, MN)
- **Become a part of our caring community and help us put health first** The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals Nurse 2 work ... Office products including Word, Excel and Outlook **Preferred Qualifications** + Utilization Review/Quality Management experience + Experience working with MCG… more
- CenterWell (Brooklyn Park, MN)
- …driver's license, auto insurance and reliable transportation. + Two years as a Registered Nurse with at least one-year of management experience in a home care, ... to sit on-site at our** **Brooklyn Park, MN** **branch location.** The **RN Clinical Manager** coordinates and oversees all direct care patient services provided by… more
- Fairview Health Services (Minneapolis, MN)
- …resource management , quality, regulatory compliance, educational opportunities, and financial management . Serves as a nurse leader and role model to ... hour schedules according to pre-established parameters. + Responsible for effective fiscal management of assigned area(s) to ensure proper utilization of… more
- Blue Cross and Blue Shield of Minnesota (Eagan, MN)
- …Skills and Experience * 2+ years of managed care experience; eg case management /health coach, utilization management and/or auditing experience (may be ... outreaches to the member, family and providers to engage in complex case management program. * Conducts clinical assessments with members and providers utilizing… more
- Highmark Health (St. Paul, MN)
- …Inc. **Job Description :** **JOB SUMMARY** This job implements effective utilization management strategies including: review of appropriateness of health ... Nursing **EXPERIENCE** **Required** + 3 years of related, progressive clinical experience in the area of specialization + Experience...is part of the compact **Preferred** + Certification in Utilization Management or a related field **SKILLS**… more
- Blue Cross and Blue Shield of Minnesota (Eagan, MN)
- …the continuum of care by leveraging member partnership, pre-service clinical utilization review, case and disease management processes, skill sets and tools. ... opportunities for connecting members to group related benefits; eg Nurse Line, Employee Assistance Program, or other specialists with...* 1+ years of managed care experience; eg case management /health coach, utilization management and/or… more
- Grifols Shared Services North America, Inc (Minneapolis, MN)
- …Academic Centers ie neurology department with residents and fellows, Infusion Suite Nurse , Clinical Pharmacists, DOP for formulary consideration and specialty ... institutions aligned with customer segmentation and enhance formulary and dosing protocols. * Utilization of Managed Markets, Marketing, Ig Nurse Educators, MSL,… more
- CVS Health (St. Paul, MN)
- …CM, discharge planning and/or home health care coordination experience + Previous Utilization Management experience, transitions of care and discharge planning ... Services and strategies, policies and programs are comprised of network management , clinical coverage, and policies. **Position Summary/Mission** Community Care… more
- Datavant (St. Paul, MN)
- …function as delegated by management Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal ... The purpose of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and… more
- Blue Cross and Blue Shield of Minnesota (Eagan, MN)
- …Skills and Experience * 1+ years of managed care experience; eg case management /health coach, utilization management and/or auditing experience. * ... You Will Have The Case Manager is a critical component of BCBSMN Care Management team as the primary clinician providing condition and case management services… more
- Sharecare (St. Paul, MN)
- …3rd parties for care management and second opinion. + Referring members to Clinical Advocates ( Nurse ) for conditions that require clinical care and case ... / new hire plan selection, claims issues, ID card issues, grievances/appeals, utilization management (UM) status, including but not limited to medical,… more
- Oracle (St. Paul, MN)
- …of analysts providing support for operationally required changes and enhancements to clinical applications, and aa group of analysts leading projects that will ... These include, but are not limited to, multiple Essential Clinical Dataset (ECD) alignments, Critical Care workflow implementation, Multi-Disciplinary Rounding,… more