Job Description Summary The Utilization Management Nurse (UMN) reports to the Manager of Case Management and Care Transitions. Under general guidance of the Nurse Case Manager Team Leader of the Service Line, the UM Nurse functions as a member of the clinical service line team facilitates optimal reimbursement through accurate certification of their assigned patients. This position conducts initial admission reviews and refers cases for secondary review when appropriate. This role ensures the adherence to regulatory requirements with Medicare, FFS Medicaid, and other government payers. The UM Nurse refers and consults with the multidisciplinary team to promote appropriate communication of the review results to hospital revenue professionals to ensure proper utilization of hospital resources for accurate reimbursement Entity Medical University Hospital Authority (MUHA) Worker Type Employee Worker Sub-Type​ Regular Cost Center CC005339 SYS - Utilization Management Pay Rate Type Salary Pay Grade Health-28 Scheduled Weekly Hours 40 Work Shift Job Description Hours per week: 40 Scheduled Work Hours/Shift: Days Fair Labor Standards Act Status: Salaried Job Summary/Purpose: Conducts utilization reviews to determine if patients are receiving care appropriate to severity of illness or condition and intensity of services required. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Consults with providers and other stakeholders as needed. Minimum Training and Education: Bachelor's degree in Nursing from an accredited school of nursing and five years of nursing work experience to include two years utilization / case management experience in a hospital setting required. Prior leadership experience preferred. Evidence of committee involvement within a healthcare setting needed (either departmental or hospital-wide). Must possess excellent verbal and written communication skills. Familiarity with InterQual and/or MCG screening criteria desired. Required Licensure, Certifications, Registrations: ​Licensure as a registered nurse by the state of South Carolina or compact state required. Additional Job Description Physical Requirements: (C)ontinuous = 6-8 hours per shift; (F)requent = 2-6 hours per shift; (I)nfrequent = 0-2 hours per shift) Ability to perform job junctions while standing (C), while sitting (I), while walking (F). Ability to climb stairs (I); work indoors (C); work from elevated areas (I); work in confined/cramped spaces (I); perform job functions from kneeling positions (I); bend at the waist (F); twist at the waist (F); squat and perform job functions(I); perform ‘pinching’ operations (I); and fully use both hands/arms (C). Ability to perform repetitive motions with hands/wrists/elbows and shoulders (F), ability to fully use both legs (C), to reach in all directions, possess good finger dexterity (C), maintain tactile sensory functions (C) and maintain good olfactory sensory function (C). Ability to lift and carry up to 50 lbs, unassisted and lift/carry patients up to 350 lbs (+/-), assisted. Ability to lift objects from floor level to height of 36 inches, up to 50 lbs, unassisted. Ability to lower objects, to 50 lbs, from height of 36 inches, unassisted. Ability to push/pull objects up to 350 lbs (+/-), unassisted. Maintain 20/40 vision, corrected. (C), see and recognize objects close at hand (C) and objects at a distance (C). Ability to match or discriminate between colors (C), to determine distance/relationship between objects; depth perception. (C) and good peripheral vision capabilities (C). Ability to maintain hearing acuity, with correction (C), ability to hear and understand whispered conversations at a distance of three feet, must be ambidextrous. Ability to perform gross motor functions with frequent fine motor movements (C). Ability to be qualified physically (by medical personnel) for respirator use, initially and annually. Ability to deal effectively with stressful situations. Computer literacy, ability to work rotating shifts, provide extended leadership coverage as needed, ability to learn and use new processes, tools equipment as required. If you like working with energetic enthusiastic individuals, you will enjoy your career with us! The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need. Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees

About Us Healing Body and Mind. NeuroPsychiatric Hospitals is a national leader in behavioral healthcare, specializing in patients with acute psychiatric and complex medical needs. Our hospitals use an interdisciplinary, multi-specialty approach that delivers high-quality, patient-centered care when it’s needed most. With locations in Indiana, Michigan, Texas, and Arizona, we’re expanding access to our unique model of care across the United States. Join us and be part of a team dedicated to making a lasting difference in the lives of patients and families every day Overview Neuropsychiatric Hospitals is looking for a Utilization Review Nurse (RN) to coordinate patients’ services across the continuum of care by promoting effective utilization, monitoring health resources and elaborating with multidisciplinary teams. This position will support multiple hospitals both remotely and traveling onsite to the hospitals. Location: REMOTE- We are looking for someone located in the Midwest area, with strong preference in Indiana, Michigan, or Ohio. Benefits of joining NPH - Competitive pay rates - Medical, Dental, and Vision Insurance - NPH 401(k) plan with up to 4% Company match - Employee Assistance Program (EAP) Programs - Generous PTO and Time Off Policy - Special tuition offers through Capella University - Work/life balance with great professional growth opportunities - Employee Discounts through LifeMart Responsibilities - Coordinate and support the hospital’s Utilization Review and Case Management program to ensure appropriate level of care, efficient resource use, and timely discharge planning. - Review patient charts and clinical documentation to verify medical necessity, severity of illness, and compliance with regulatory and care guideline standards (InterQual and Milliman). - Conduct admission, concurrent, and length-of-stay reviews and communicate with payors regarding precertification, concurrent reviews, and authorizations. - Collaborate with physicians, nursing staff, medical records, and finance to ensure accurate documentation and appropriate reimbursement. - Monitor patient progress and coordinate care management strategies to support positive patient outcomes and reduce unnecessary length of stay. - Identify utilization trends or documentation gaps and recommend process improvements to enhance quality and financial outcomes. - Participate in multidisciplinary care coordination meetings and communicate with internal teams, families, and external providers as needed. - Prepare reports and maintain documentation related to utilization review, denial management, and regulatory compliance. - Maintain knowledge of current regulatory, accreditation, and reimbursement requirements related to utilization management and case management. Qualifications - Education: High School Diploma or GED and graduate from an accredited LPN program or Associate Degree in Nursing required. Bachelor or Masters of Science in Nursing or Behavioral Health field preferred. - Experience: Minimum of 4 years of utilization review experience in a hospital setting required. Minimum of 2 years of case management experience, including discharge planning in a hospital setting preferred.. - Licensure: Registered Nurse (RN) or Licensed Practical Nurse (LPN) in the state of practice required. Certified Case Manager (CCM), or Accredited Case Manager (ACM) preferred. - Ability to work independently and collaboratively within a multidisciplinary team environment. - Strong organizational and time management skills with the ability to prioritize tasks and manage a changing workload. - Ability to analyze patient care data, develop criteria, and apply patient care methodologies. - Experience abstracting and presenting data in a clear, professional manner for medical committees or leadership. - Strong attention to detail with accurate documentation and data entry skills. - Ability to maintain strict confidentiality and protect patient privacy. - Ability to build and maintain effective working relationships with physicians, clinical staff, medical records personnel, social workers, patients, and the public. - Strong communication skills, both written and verbal, including the ability to explain clinical and case management information to patients, families, and healthcare providers. - Knowledge of care management plans, critical pathways, and case management practices. - Knowledge of healthcare regulations and accreditation standards, including Case Management, Utilization Management, Risk Management, and HFAP/JCAHO requirements. - Familiarity with hospital policies, medical staff bylaws, and community resources. - Proficiency with Microsoft Office applications, email, and computer systems. - Strong problem-solving and basic research skills. - Knowledge of medications and patient care management practices. - Travel flexibility up to 50–70% as required.

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. *Must be licensed in California Position Purpose: Performs concurrent reviews, including determining member's overall health, reviewing the type of care being delivered, evaluating medical necessity, and contributing to discharge planning according to care policies and guidelines. Assists evaluating inpatient services to validate the necessity and setting of care being delivered to the member. - Performs concurrent reviews of member for appropriate care and setting to determine overall health and appropriate level of care - Reviews quality and continuity of care by reviewing acuity level, resource consumption, length of stay, and discharge planning of member - Works with Medical Affairs and/or Medical Directors as needed to discuss member care being delivered - Collects, documents, and maintains concurrent review findings, discharge plans, and actions taken on member medical records in health management systems according to utilization management policies and guidelines - Works with healthcare providers to approve medical determinations or provide recommendations based on requested services and concurrent review findings - Assists with providing education to providers on utilization processes to ensure high quality appropriate care to members - Provides feedback to leadership on opportunities to improve appropriate level of care and medically necessity based on clinical policies and guidelines - Reviews member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities - Collaborates with care management on referral of members as appropriate - Performs other duties as assigned. - Complies with all policies and standards. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of related experience. 2+ years of acute care experience required. Clinical knowledge and ability to determine overall health of member including treatment needs and appropriate level of care preferred. Knowledge of Medicare and Medicaid regulations preferred. Knowledge of utilization management processes preferred. License/Certification: - For Health Net of California: RN license required - **Must be licensed in California Location: Position is remote. Hours: 8:00-5:00 PST. Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

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