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Contract Utilization Review Jobs in Georgia (NOW HIRING)

Elevance Health

Med Mgmt Clinician Sr (contract)

Atlanta, GA · Remote

$27 - $34.50/hr

Requires a minimum of 6 years of clinical experience and/or utilization review experience ... Contract to hire Additional Details: * Schedule: Monday - Friday, 8:00 AM - 5:00 PM PST (must work ...

NICE

Business Program Manager - SLED

Atlanta, GA · On-site

$48K - $53K/yr

Track contract utilization and performance, identifying opportunities to optimize scope, usability ... reviews and approvals. * Exceptional communication, analytical, and project management skills

Dane Street

Board-Certified Psychiatrist

Savannah, GA · On-site

Our physician panel is comprised of independent contract reviewers (1099) compensated on a per-case ... and utilization review/management expertise * Expanded credentials as an expert in Independent ...

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Contract Utilization Review information

What are the key skills and qualifications needed to thrive in contract utilization review?

To thrive in Contract Utilization Review, you need a solid understanding of medical terminology, insurance policies, and contract compliance, often supported by a healthcare-related degree or certification in utilization management. Familiarity with utilization review software, electronic medical records (EMR), and knowledge of regulatory standards such as CMS guidelines is essential. Strong analytical thinking, attention to detail, and effective communication skills are crucial for collaborating with care teams and insurers. These abilities ensure reviews are accurate, contracts are properly administered, and patient care meets organizational and payer requirements.

What does a contract utilization review do?

A typical day in Contract Utilization Review involves reviewing patient medical records, ensuring adherence to payer contracts and regulatory standards, and communicating with healthcare providers to validate medical necessity of services. Professionals in this role often collaborate with clinical staff, case managers, and insurance representatives to resolve discrepancies or authorization issues. The work is detail-oriented and deadline-driven, making organizational skills vital. This dynamic position offers significant opportunities to learn more about healthcare regulations and may serve as a stepping stone toward more advanced roles in healthcare administration or compliance.

What is a contract utilization review?

A Contract Utilization Review job involves analyzing and evaluating the usage of contracts to ensure compliance, cost-effectiveness, and efficiency. Professionals in this role review contract terms, monitor vendor performance, and assess utilization data to optimize contract value. They may work in industries such as healthcare, government, or procurement, ensuring that agreements are being properly executed. The goal is to identify areas for improvement, reduce waste, and enhance operational efficiency.

What are the most commonly searched types of Utilization Review jobs in Georgia? The most popular types of Utilization Review jobs in Georgia are:
What are popular job titles related to Contract Utilization Review jobs in Georgia? For Contract Utilization Review jobs in Georgia, the most frequently searched job titles are:
What job categories do people searching Contract Utilization Review jobs in Georgia look for? The top searched job categories for Contract Utilization Review jobs in Georgia are:
What cities in Georgia are hiring for Contract Utilization Review jobs? Cities in Georgia with the most Contract Utilization Review job openings:
Contract Utilization Review jobs near you
Infographic showing various Contract Utilization Review job openings in Georgia as of August 2026, with employment types broken down into 100% Full Time. Highlights an 100% Remote job distribution.

RN Patient Care Coordinator in Atlanta, GA

Vivian Health

Atlanta, GA • On-site

Other

Re-posted 1 hour ago

Job description

Patient Care Coordinator RN
Job Summary:
Responsible for optimizing quality and efficiency of care for hospitalized members by conducting daily utilization and quality reviews, discharge planning, and care coordination. Collaborates with physicians and multidisciplinary teams, developing safe discharge plans, and ensuring compliance with all relevant regulations. The role promotes high customer satisfaction and achieves desired utilization and quality outcomes for the population served. Essential Responsibilities:
  • Utilizes established criteria, to perform daily inpatient review activities, including prospective, concurrent, and retrospective utilization review for all members requiring inpatient admission.
  • Performs an admission utilization review upon admission.
  • Assesses discharge planning needs and documents assessment using designated tools in EMR for all new inpatient admissions within 24 hours and begins the discharge planning process immediately.
  • Conducts a concurrent utilization review of all patients daily and as appropriate based on criteria and policy.
  • Assess daily all patients for post-hospital care planning and coordinate discharge plans, ensuring appropriate level of care in the most suitable setting.
  • Performs daily bedside rounds on patients and/or significant other to update on discharge planning.
  • Reviews charts daily to ensure progression of plan of care and to prepare for daily discharge planning needs.
  • Escalate barriers to discharge in real time after usual processes cannot affect discharge.
  • Leverages written escalation pathways to ensure timely care and timely discharge for patients.
  • Establishes and evolves a discharge plan in parallel with the medical plan to ensure patients discharge plan is ready at the same time as medical clearance.
  • Perform and documents a social screening assessment for all patients admitted to hospital and places referrals to internal programs and social workers as appropriate.
  • Prepares for and attends all scheduled rounds with physician partners and leaders to discuss clinical courses, discharge planning, barriers to care / discharge and quality concerns.
  • Communicate regularly with hospitalist partners and other healthcare team members to monitor patient progress and address delays or quality issues.
  • Establishes and maintains contact with patients and their families as appropriate, including the provision of education when needed and planning for discharge along the hospital stay.
  • Arranges follow up appointments for medical and surgical patients who are discharged home as needed.
  • Ensure that the appropriate level of care is being delivered in the most appropriate setting.
  • Performs quality of care and service reviews using identified quality indicators.
  • Performs readmission reviews and identifies plan of care for discharge to prevent future readmissions.
  • Send appropriate referrals for post-acute needs.
  • Secure post-acute services for discharging patients in advance of medical clearance.
  • Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management.
  • Maintains effective interaction/communication with members of the medical staff, nursing staff, complex case managers, home care review team, social workers, general reviewers, referral coordinators, and Kaiser Permanente medical offices to facilitate the inpatient utilization management process and to provide continuity of care.
  • Builds effective working relationships with physicians, department staff, post-acute staff, vendors, and other departments within the health plan.
  • Assists in the development and revision of guidelines, pathways and protocols.
  • Coordinate case conferences for complex cases and facilitate transfers to appropriate facilities.
  • Documents a daily progress note in EMR with evolving discharge plan
  • Refers cases identified as risk or quality issues to the appropriate department for review using the appropriate reporting tool.
  • Document Review Activities to include (according to policy): Medical necessity for admission. Medical necessity for continued stay. Estimated length of stay. Diagnoses. Procedures performed. Demographic Data. Discharge Planning. Physicians are involved in care.
  • Issue letters of non-coverage to members not meeting inpatient level of care criteria per established criteria and policy and procedure.
  • Works cross-functionally with other departments in striving to meet organizational goals and objectives.
  • Achieves and maintains an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case/utilization management.
  • Knowledgeable and compliant with regional personnel policies and procedures.
  • Knowledgeable and compliant with QRM departmental and unit specific policies and procedures.
  • Participates in annual regional and departmental compliance training.
  • Knowledgeable and compliant with Principles of Responsibility.
  • Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and license requirements (if applicable), and Kaiser Permanentes policies and procedures.
  • Responsible for assisting the Medical Office Administration, Customer Services and Provider Relations in investigating concerns and issues.
  • Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform the job.
  • Demonstrates understanding of HIPAA privacy regulations by maintaining confidentiality of Protected Health Information (PHI).
  • Demonstrates doing the right thing and doing things the right way is an underlying premise in all work-related activities and can identify location of copy of Principles of Responsibility.
  • Develops and maintains an awareness of how to report compliance issues and concerns. Escalates compliance issues to immediate or appropriate supervisors.
  • Refers to physician advisor when there is disagreement on patient class, level of care, continued stay or discharge.
  • Other duties as assigned.

Basic Qualifications: Experience
  • Minimum two (2) years of RN experience in utilization/case management, discharge planning, quality improvement, or patient care delivery in a healthcare setting.
Education
  • Bachelors Degree in Nursing or four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required.
License, Certification, Registration
  • Registered Professional Nurse License (Georgia)
     
Additional Requirements:
  • Working knowledge of all relevant federal, state, local and regulatory requirements.
  • Functional knowledge of computers and experience with managed health care delivery, including Medicare.
  • Advanced communication and interpersonal skills with all levels of internal and external customers.
  • Ability to collaborate effectively with multidisciplinary healthcare teams.
  • Excellent time management skills; ability to work in a fast-paced environment.
  • Experience in a health plan environment is highly desirable.
Preferred Qualifications:
  • Minimum three (3) years of clinical nursing experience, preferably in complex or acute care settings preferred.
  • Minimum two (2) years of experience in utilization review, case management, and discharge planning preferred.
  • Complex Case Management Certification (CCM) preferred.
  • Knowledge of funding, resources, services, and outcomes preferred.
  • Masters degree in nursing, Health Care, or Case Management preferred.
Notes:
  • Monday thru Friday with rotating weekends and holidays

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