Assesses compliance to regulatory and health plan requirements for authorization, including ... May participate in the Utilization Review Committee to present medical necessity data and outcomes ...
Assesses compliance to regulatory and health plan requirements for authorization, including ... May participate in the Utilization Review Committee to present medical necessity data and outcomes ...
Assesses compliance to regulatory and health plan requirements for authorization, including ... May participate in the Utilization Review Committee to present medical necessity data and outcomes ...
Assesses compliance to regulatory and health plan requirements for authorization, including ... May participate in the Utilization Review Committee to present medical necessity data and outcomes ...
Assesses compliance to regulatory and health plan requirements for authorization, including ... May participate in the Utilization Review Committee to present medical necessity data and outcomes ...
Assesses compliance to regulatory and health plan requirements for authorization, including ... May participate in the Utilization Review Committee to present medical necessity data and outcomes ...
Prior Authorization Assistant
Saint Cloud, MN · On-site
$21.12 - $31.68/hr
The Prior Authorization team processes all health plan/payer utilization review requirements, which include managed care referrals, pre-certifications, and prior authorizations in a timely and ...
Prior Authorization Assistant
Saint Cloud, MN · On-site
$21.12 - $31.68/hr
The Prior Authorization team processes all health plan/payer utilization review requirements, which include managed care referrals, pre-certifications, and prior authorizations in a timely and ...
Prior Authorization Assistant
$20.71 - $31.68/hr
The Prior Authorization team processes all health plan/payer utilization review requirements, which include managed care referrals, pre-certifications, and prior authorizations in a timely and ...
Prior Authorization Assistant
$20.71 - $31.68/hr
The Prior Authorization team processes all health plan/payer utilization review requirements, which include managed care referrals, pre-certifications, and prior authorizations in a timely and ...
Prior Authorization Assistant
$20.71 - $31.68/hr
The Prior Authorization team processes all health plan/payer utilization review requirements, which include managed care referrals, pre-certifications, and prior authorizations in a timely and ...
Prior Authorization Assistant
$20.71 - $31.68/hr
The Prior Authorization team processes all health plan/payer utilization review requirements, which include managed care referrals, pre-certifications, and prior authorizations in a timely and ...
Director of Utilization Management
$237K - $248K/yr
... utilization reviews ... They manage and monitor prior authorizations and concurrent reviews through the clinical appeals ...
Director of Utilization Management
$237K - $248K/yr
... utilization reviews ... They manage and monitor prior authorizations and concurrent reviews through the clinical appeals ...
Director of Utilization Management
Eagan, MN · On-site
$237K - $248K/yr
... utilization reviews ... They manage and monitor prior authorizations and concurrent reviews through the clinical appeals ...
Director of Utilization Management
Eagan, MN · On-site
$237K - $248K/yr
... utilization reviews ... They manage and monitor prior authorizations and concurrent reviews through the clinical appeals ...
RN - Admissions Acute
$42 - $48.80/hr
... utilization review processes to assure continuity for the most appropriate level of care for ... Perform insurance benefit verifications and secure initial pre-authorization for treatment and ...
RN - Admissions Acute
$42 - $48.80/hr
... utilization review processes to assure continuity for the most appropriate level of care for ... Perform insurance benefit verifications and secure initial pre-authorization for treatment and ...
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
... prior authorization (if needed), scheduling, and admission What Makes You a Great Fit * Master ... utilization review, financial counseling, and site operations (required) * Experience with ...
... prior authorization (if needed), scheduling, and admission What Makes You a Great Fit * Master ... utilization review, financial counseling, and site operations (required) * Experience with ...
Clinical Appeals Specialist II-Hybrid
Rochester, MN · On-site
$88.36 - $123.78/hr
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
Clinical Appeals Specialist II-Hybrid
Rochester, MN · On-site
$88.36 - $123.78/hr
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
Staff Pharmacist
Spring Park, MN · On-site
$70/hr
Perform drug utilization review -- check for interactions, contraindications, allergies, and dosing ... Resolve third-party billing issues, prior authorizations, and rejected claims. * Contact ...
Quick apply
Staff Pharmacist
Spring Park, MN · On-site
$70/hr
Perform drug utilization review -- check for interactions, contraindications, allergies, and dosing ... Resolve third-party billing issues, prior authorizations, and rejected claims. * Contact ...
This position is accountable for the day-to-day and strategic activities of the assigned review ... authorizations. In addition, this position is responsible for process documentation and ...
This position is accountable for the day-to-day and strategic activities of the assigned review ... authorizations. In addition, this position is responsible for process documentation and ...
Clinical Appeals Specialist II-Hybrid
Rochester, MN · Hybrid
$88K - $123K/yr
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
Clinical Appeals Specialist II-Hybrid
Rochester, MN · Hybrid
$88K - $123K/yr
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review ...
This position is accountable for the day-to-day and strategic activities of the assigned review ... authorizations. In addition, this position is responsible for process documentation and ...
This position is accountable for the day-to-day and strategic activities of the assigned review ... authorizations. In addition, this position is responsible for process documentation and ...
This position is accountable for the day-to-day and strategic activities of the assigned review ... authorizations. In addition, this position is responsible for process documentation and ...
This position is accountable for the day-to-day and strategic activities of the assigned review ... authorizations. In addition, this position is responsible for process documentation and ...
RN - Admissions Acute
Saint Paul, MN · On-site
$42 - $48.80/hr
... utilization review processes to assure continuity for the most appropriate level of care for ... Perform insurance benefit verifications and secure initial pre-authorization for treatment and ...
RN - Admissions Acute
Saint Paul, MN · On-site
$42 - $48.80/hr
... utilization review processes to assure continuity for the most appropriate level of care for ... Perform insurance benefit verifications and secure initial pre-authorization for treatment and ...
Authorization Utilization Review information
What is authorization utilization review?
Authorization Utilization Review is a process used by healthcare organizations and insurance companies to assess the medical necessity and appropriateness of medical services before they are provided. The main goal is to ensure that patients receive care that is effective, efficient, and covered by their health plan. This review typically involves evaluating patient records, treatment plans, and provider requests to decide if the requested services meet established guidelines. By doing so, it helps control healthcare costs and ensures quality care for patients.
What are the key skills and qualifications needed to thrive as an authorization utilization review specialist?
To thrive as an Authorization Utilization Review Specialist, you need a solid understanding of medical terminology, healthcare regulations, and insurance policies, often backed by a clinical background or relevant certifications. Familiarity with utilization management software, electronic health records (EHR), and payer portals is typically required. Strong attention to detail, analytical thinking, and effective communication are vital soft skills for coordinating with providers and payers. These skills ensure accurate authorization decisions, regulatory compliance, and efficient patient care coordination.
What are some common challenges faced by professionals in authorization utilization review roles, and how can they be addressed?
Professionals in Authorization Utilization Review often encounter challenges such as managing high caseloads, navigating complex insurance guidelines, and ensuring timely communication with providers and patients. Staying organized and up-to-date with evolving payer requirements is essential to avoid delays or denials. Building strong collaboration with clinical teams and leveraging electronic health record systems can help streamline workflows and improve efficiency in the review process.
What is the difference between Authorization Utilization Review vs Claims Reviewer?
| Aspect | Authorization Utilization Review | Claims Reviewer |
|---|---|---|
| Credentials | Typically requires healthcare or insurance-related certifications, such as RN, CPC, or licensed healthcare professionals | Often requires similar credentials, focusing on insurance policies and claims processing |
| Work Environment | Hospitals, insurance companies, healthcare facilities | Insurance companies, third-party administrators, healthcare organizations |
| Industry Usage | Used to assess medical necessity before approving services | Used to evaluate claims for payment accuracy and compliance |
Authorization Utilization Review and Claims Reviewer roles both involve insurance and healthcare knowledge, but Authorization Utilization Review focuses on pre-authorization of services, while Claims Review centers on post-service claims assessment. Understanding these differences helps clarify career paths and job expectations in healthcare insurance.
What are popular job titles related to Authorization Utilization Review jobs in Minnesota?
For Authorization Utilization Review jobs in Minnesota, the most frequently searched job titles are:
- No Experience Utilization Review Nurse
- Remote Medical Record Review Nurse
- Evening Utilization Review Nurse
- Temporary Utilization Review Nurse
- Appeals Nurse
- Evening Optum Health Utilization Review
- Optum Clinical Claim Review Nurse
- Behavioral Health Utilization Review
- Remote Utilization Review Rn
- Per Diem Remote Chart Review Nurse
What job categories do people searching Authorization Utilization Review jobs in Minnesota look for?
The top searched job categories for Authorization Utilization Review jobs in Minnesota are:
- Insurance Utilization Review
- Work From Home Utilization Review
- Remote Dental Utilization Review
- Utilization Review Coordinator Remote
- Remote Cigna Utilization Review Nurse
- Chart Utilization Review
- Utilization Review Clinician Salary
- Registered Nurse Reviewer
- Locum Medical Utilization Review Physician
- Overnight Remote Utilization Review
Manager (RN) - Utilization Review
Minneapolis, MN • On-site
Hennepin Healthcare •
Health Care and Social Assistance • 5 - 10K employees5,001 - 10,000 employees
7.6
Based on 42 frontline employees who took The Breakroom Quiz
189th of 893 rated healthcare providers
Great coworkers
People enjoy working here
Good employer
Recommended by students
Respectful managers
Full-time
Re-posted 14 days ago
Job description
Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St. Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.
Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.
JOB DETAILS
Department: Utilization Management
FTE: 1.0 (80 hours per pay period)
Shift(s): Days
Location: Remote with onsite presence as needed
Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.
We are currently seeking a Utilization Review Manager to join our Transitional Care Team. This is a full-time management role with remote capability.
Purpose of this position: Manages the design, development, implementation, and monitoring of utilization review functions. 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 resource on issues related to the appropriate utilization of resources, coordination of payer communication, and utilization review and management. Responsible for carrying out duties in a manner to assure success in financial management, human resources management, leadership, quality, and operational management objectives. Participates in program development and UR Department performance improvement. Responsible for day-to-day operations of the department, assists with the budgeting process, assists with personnel recruitment, retention, corrective action, and professional development.
RESPONSIBILITIES:
QUALIFICATIONS:
Minimum Qualifications:
Preferred Qualifications:
Knowledge/ Skills/ Abilities:
License/Certifications:
You've made the right choice in considering Hennepin Healthcare for your employment. We offer a wealth of opportunities for individuals who want to make an impact in our patients' lives. We are dedicated to providing Equal Employment Opportunities to both current and prospective employees. We are driven to connect talented individuals with life-changing career opportunities, enabling you to provide exceptional care without exception. Thank you for considering Hennepin Healthcare as a future employer.
Please Note: Offers of employment from Hennepin Healthcare are conditional and contingent upon successful clearance of all background checks and pre-employment requirements.
Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.
JOB DETAILS
Department: Utilization Management
FTE: 1.0 (80 hours per pay period)
Shift(s): Days
Location: Remote with onsite presence as needed
Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin.
We are currently seeking a Utilization Review Manager to join our Transitional Care Team. This is a full-time management role with remote capability.
Purpose of this position: Manages the design, development, implementation, and monitoring of utilization review functions. 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 resource on issues related to the appropriate utilization of resources, coordination of payer communication, and utilization review and management. Responsible for carrying out duties in a manner to assure success in financial management, human resources management, leadership, quality, and operational management objectives. Participates in program development and UR Department performance improvement. Responsible for day-to-day operations of the department, assists with the budgeting process, assists with personnel recruitment, retention, corrective action, and professional development.
RESPONSIBILITIES:
- Participates in the development and management of department budgets and productivity targets
- Directs and manages team of UR Coordinators, promotes employee satisfaction, supports staff development, and utilizes the progressive discipline process when appropriate
- Collaborates with department director and professional development specialist to develop standard work and expectations for the utilization review process, including timely medical necessity screening to ensure patients are placed at the appropriate patient status and level of care, professional communication with physicians and nurses and other members of the care team
- Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status
- Ensures processes are in place for proactive reviews of surgical and other procedures to confirm accurate perioperative pre-authorization and patient class order reconciliation process. Assesses compliance to regulatory and health plan requirements for authorization, including Medicare
Inpatient Only List and communicates to provider to obtain accurate order prior to procedure and post procedure - Ensures UR Coordinators and Clinical Coordinators identify, document, and communicate avoidable days and delays in services that may prolong length of stay; analyzes data to monitor trends for opportunities to improve services. Partners with hospital Director Transitional Care to report avoidable days, trends, and actions to UR Committees, as appropriate
- Partners with Physician Advisor to engage in second level review and working with attending physicians to document completely to ensure patient class determinations
- Serves as expert resource for all Medicare Notification Letters and ensures appropriate distribution of all letters (IMM, MOON, HINN, etc.) including full documentation to meet regulatory requirements and ensure correct billing
- Works collaboratively with Inpatient Care Management, Patient Accounting, Patient Admission and Registration, HIM, and the Finance Department to analyze one-day Medicare inpatient stays and identify opportunities to improve
- Develops and implements process to manage and respond to all concurrent and post-discharge third party payer denials of outpatient and inpatient cases alleged to be medically inappropriate. Including, but not limited to; Peer-to-Peer as appropriate, written appeal letters when indicated, documentation of interventions and outcomes and monitor to identify opportunities to improve processes for denial
prevention - Serves as the internal expert on documentation and reimbursement requirements. Serves as a resource to the health care team for utilization and denial management. Liaises with provider office staff and facilitates meetings with payers, as appropriate
- May participate in the Utilization Review Committee to present medical necessity data and outcomes and partners with care management leadership to develop action plans for improvement
- Performs other duties as assigned
QUALIFICATIONS:
Minimum Qualifications:
- Bachelors degree in nursing or related field
- Three to five (3 to 5) years of leadership experience (i.e., charge nurse, team leader, preceptor, committee chair, etc.)
- Five (5) years clinical experience.
- A minimum of one (1) year of utilization review experience
Preferred Qualifications:
- Masters' degree
- CPHM (Certified Professional in Healthcare Management), CCM (Certified Case Manager), or ACM (Accredited Case Manager)
- Experience in surgery, emergency and/or critical care
- Experience in process/quality improvement, quality measurement, data abstraction, data analysis and reporting, and data integrity
Knowledge/ Skills/ Abilities:
- Ability to deliver financial results for areas of accountability
- Knowledge of or ability to learn financial management related to UR function and reporting, quality improvement processes, and human
resources management - Able to effectively monitor, evaluate and administer the resources of each assigned area, and make substantiated recommendations regarding
resource allocation needs for future planning purposes - Able to communicate effectively in writing and verbally, ability to interact with a wide variety of individuals, and handle complex and confidential
situations - Ability to lead, delegate, analyze information and problem solve
- Demonstrates evidence of strong skills in confidentiality, integrity, creativity, and initiative
License/Certifications:
- Current Registered Nurse licensure from the Minnesota Board of Nursing upon hire
You've made the right choice in considering Hennepin Healthcare for your employment. We offer a wealth of opportunities for individuals who want to make an impact in our patients' lives. We are dedicated to providing Equal Employment Opportunities to both current and prospective employees. We are driven to connect talented individuals with life-changing career opportunities, enabling you to provide exceptional care without exception. Thank you for considering Hennepin Healthcare as a future employer.
Please Note: Offers of employment from Hennepin Healthcare are conditional and contingent upon successful clearance of all background checks and pre-employment requirements.
About Hennepin Healthcare
Sourced by ZipRecruiter
Industry
Health care and social assistance
Company size
5,001 - 10,000 Employees
Headquarters location
Minneapolis, MN, US
Year founded
1887
Website
What Hennepin Healthcare employees say
Pay
Benefits
Hours and flexibility
Workplace
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