PR · On-site
The Utilization Review (UR) Director is responsible for overseeing the utilization management ... Valid membership for Social Work and Psychiatric Nursing * A minimum of five years' experience in ...
Utilization Coordinator
San Juan, PR · On-site
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...
Utilization Coordinator
San Juan, PR · On-site
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...
PR · On-site
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...
PR · On-site
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...
Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...
$60 - $80/hr
... utilization review processes to assure continuity for the most appropriate level of care for ... Clear and active nursing license in the state. * CPR and de-escalation/restraint certification ...
New
$60 - $80/hr
... utilization review processes to assure continuity for the most appropriate level of care for ... Clear and active nursing license in the state. * CPR and de-escalation/restraint certification ...
New
... utilization review processes to assure continuity for the most appropriate level of care for ... Clear and active nursing license in the state. * CPR and de-escalation/restraint certification ...
... utilization review processes to assure continuity for the most appropriate level of care for ... Clear and active nursing license in the state. * CPR and de-escalation/restraint certification ...
PR · On-site
... utilization review processes to assure continuity for the most appropriate level of care for ... Clear and active nursing license in the state. * CPR and de-escalation/restraint certification ...
PR · On-site
... utilization review processes to assure continuity for the most appropriate level of care for ... Clear and active nursing license in the state. * CPR and de-escalation/restraint certification ...
Case Manager
Manati, PR · On-site
$17 - $21.75/hr
Participate in utilization review process: data collection, trend review, and resolution actions ... For Nursing, must possess minimum of an Associate Degree in Nursing, RN licensure with BSN ...
Case Manager
Manati, PR · On-site
$17 - $21.75/hr
Participate in utilization review process: data collection, trend review, and resolution actions ... For Nursing, must possess minimum of an Associate Degree in Nursing, RN licensure with BSN ...
Especialista En Revisión De Utilización Hospitalaria
San Juan, PR · On-site
$60 - $80/hr
Bachelor's Degree in Nursing. At least one (1) year of experience working in a clinical area and reviewing hospital utilization, preferably in the Health Insurance Industry. Certifications / Licenses:
Especialista En Revisión De Utilización Hospitalaria
San Juan, PR · On-site
$60 - $80/hr
Bachelor's Degree in Nursing. At least one (1) year of experience working in a clinical area and reviewing hospital utilization, preferably in the Health Insurance Industry. Certifications / Licenses:
PR · On-site
Provide backup to Utilization Review Department out of business hours including document in the ... Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling ...
Provide backup to Utilization Review Department out of business hours including document in the ... Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling ...
PR · On-site
Provide backup to Utilization Review Department out of business hours including document in the ... Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling ...
... the utilization of triage nurses, Practitioners, Pharmacist and administrative staff ... reviewing and documenting medical outpatient and inpatient electronic health records, as well as ...
... the utilization of triage nurses, Practitioners, Pharmacist and administrative staff ... reviewing and documenting medical outpatient and inpatient electronic health records, as well as ...
Medical Support Assistant (Advanced)
San Juan, PR · On-site
$45K/yr
Coordinates with the patient care team to review clinic appointment availability (utilization) to ... nursing staff) to accomplish team goal setting to ensure medical care to patients is met. ii. ...
Medical Support Assistant (Advanced)
San Juan, PR · On-site
$45K/yr
Coordinates with the patient care team to review clinic appointment availability (utilization) to ... nursing staff) to accomplish team goal setting to ensure medical care to patients is met. ii. ...
$41K - $78K/yr
... utilization, and clinical excellence. Educate physicians, fellows, nurses, and staff through ... be reviewed at www.bscbenefitsconnect.com. Actual compensation will be commensurate with ...
$41K - $78K/yr
... utilization, and clinical excellence. Educate physicians, fellows, nurses, and staff through ... be reviewed at www.bscbenefitsconnect.com. Actual compensation will be commensurate with ...
Freelance Utilization Review Nurse information
What is a freelance utilization review nurse?
A Freelance Utilization Review Nurse is a registered nurse who independently reviews medical records to determine the necessity, efficiency, and appropriateness of healthcare services. They work on a contract basis for insurance companies, healthcare organizations, or third-party review agencies. Their primary role is to ensure that treatments meet established guidelines and are cost-effective. Unlike full-time utilization review nurses, freelancers have the flexibility to choose their workload and clients. This role requires strong analytical skills, clinical experience, and knowledge of insurance policies and healthcare regulations.
What skills and qualifications are needed to thrive as a freelance utilization review nurse?
To thrive as a Freelance Utilization Review Nurse, you need a valid RN license, strong clinical assessment skills, and experience in care management or utilization review. Familiarity with electronic medical records (EMRs), utilization management software, and understanding of insurance guidelines or regulations such as Medicare and Medicaid are crucial. Attention to detail, critical thinking, and effective verbal and written communication help you excel when working independently and reviewing complex medical records. These abilities ensure accurate case evaluations, regulatory compliance, and constructive collaboration with healthcare providers and insurance representatives.
What are the common work environments and daily responsibilities of a freelance utilization review nurse?
Freelance Utilization Review Nurses typically work remotely, reviewing patient medical records, evaluating treatment plans for medical necessity, and documenting findings for insurance or healthcare organizations. Daily tasks often involve communicating with physicians and case managers to gather additional information or clarify details in patient care. You may also handle a flexible caseload, prioritize urgent reviews, and ensure all documentation meets regulatory standards. This independent work structure offers flexibility but requires organization and strong self-motivation to manage priorities and deadlines. Collaboration is usually virtual, using secure platforms to connect with healthcare team members and clients.
What are the most commonly searched types of Utilization Review Nurse jobs in Puerto Rico?
The most popular types of Utilization Review Nurse jobs in Puerto Rico are:
What are popular job titles related to Freelance Utilization Review Nurse jobs in Puerto Rico?
For Freelance Utilization Review Nurse jobs in Puerto Rico, the most frequently searched job titles are:
What job categories do people searching Freelance Utilization Review Nurse jobs in Puerto Rico look for?
The top searched job categories for Freelance Utilization Review Nurse jobs in Puerto Rico are:
Universal Health Services rating
6.8
Based on 255 frontline employees who took The Breakroom Quiz
495th of 898 rated healthcare providers
Job description
Responsibilities
Provides strategic leadership to the daily operations of the Utilization Review Department. The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. Oversee the utilization reviews, organization determinations and appeals processes in accordance with established policies and procedures. The UR Director maintains full compliance with CMS regulatory standards for utilization reviews and appeals as outlined in the CMS Managed Care Manual, as well as local and national coverage determinations, the Puerto Rico Insurance Commissioner's Office, the Office of Personnel Management (OPM), and relevant accrediting bodies. Additionally, the UR Director must comply with URAC and NCQA standards. Ensure that denial and appeal letters are responded to in accordance with industry standards .
Responsibilities and essential duties:
Oversee Utilization Review Processes: Leads the utilization review procedures in accordance with the standards set by all relevant accrediting and regulatory agencies, including URAC, CMS, NCQA, PR Insurance Commissioner's Office, and the Office of Personal Management (OPM), as well as by the health insurance industry, among others. Manage and supervise the UR team, setting standards for reviewing mental health services to ensure compliance with clinical protocols, and organizational policies. Keep abreast of any legal or regulatory changes that impact on the UR functions and operations to ensure timely implementation. Supervise the review process to ensure that requests for mental health treatment are approved or denied based on established clinical criteria and medical necessity guidelines. Conduct regular audits of utilization reviews to ensure adherence to policies and procedures, documentation of cases in established tools, use of best practices, and ethical standards. Available daily for case analysis, as required. Responsible for making sure that the denial and appeal letters are documented and mailed in the timeframe established by regulatory organization and industry standards. Identify potential risks related to mental health service delivery and utilization, including under-utilization or over-utilization of services. Develop strategies to mitigate risks and improve the timeline to respond to preauthorization request through efficient resource management. Ensure Compliance and Quality Control Provides assertive, effective, and consistent supervision to assure quality control and service excellence. Ensure compliance in the preparation and implementation of established corrective action plans and their timeframes as result of internal and external audit findings as required by FHC's and Client's Compliance Departments. Ensure an effective communication with supervised personnel regarding the findings and plans that need implementation. Assures that the census count of the members admitted to the different facilities is done daily to allocate the corresponding resources to assure compliance with utilization concurrent and retrospective reviews and authorization in the electronic platform, according to industry standards. Contributes to the compliance with specific organizational and individual goals of the position based on the financial targets. Complies with agencies recommendations responsible for monitoring our work, for example, health plans, CMS, NCQA, the Insurance Commissioner's Office, Office of Personal Management (OPM) and URAC. Supervises the Interrater Reliability Tests with the VP of Clinical Affairs and Medical Director. Analyze utilization data to identify trends, inefficiencies, and opportunities for cost-saving without compromising patient care. Prepare and present reports on utilization trends, key performance indicators, and opportunities for improvement. Prepares and delivers on time the reports required by the position, such as UR annual plan, Universes, Quality Indicators, SNP'S report, surveys, program descriptions, and corrective actions plans (as required) among others. Responsible for conducting internal audits within UR Department. Works in conjunction with all departments of the organization, including Quality for the development, implementation and monitoring of quality improvement programs. Comply with FHC Compliance Department requests to assure internal and clients' compliance requirements. Training and Development Train UR staff and psychiatrists in the best practices, regulatory requirements, and documentation standards. Provide ongoing education on evidence-based practices and updates in mental health treatment guidelines. Identifies areas of development for the staff and coordinates the training needed to strengthen the performance of supervised employees. Encourages the staff attendance and participation to the educational activities. Communication Demonstrates effective communication skills and reports to the VP of Clinical Affairs. Maintains open communication with peers and the staff. Keeps the staff informed about changes or situations related to department processes. Meet with staff on a regular basis, one on one, and conduct monthly meetings or as needed. Serve as the primary liaison with insurance companies, regulatory bodies, and other stakeholders regarding UM processes. Communicate with patients and families about treatment options and the rationale for service denials, when appropriate. Maintains effective interdependence processes and communication with the case management program and Access Center to work on organizational strategies and goals. Some examples are referral process and follow-up, analysis of the strategies to mitigate negative utilization trends such as, but not limited to, readmissions. Demonstrates initiative in integration efforts across all levels of care and with other components of health care delivery system. Works in collaboration with other departments of the organization. Represents the organization in different activities and meetings. Develop and Implement Policies In conjunction with the VP of Clinical Affairs work with development and revision of departmental policies, program description, procedures, and annual plan. Establish and update UR policies and procedures to optimize services and resource use. Ensure staff adherence to protocols regarding case reviews, authorization processes, and members' assessments. Effectively manages staff related matters in accordance with the rules, personnel policies and procedures. Develops an annual vacation plan taking into consideration the service needs and the employees requests. Keeps the specialization license and professional association membership ( colegiación ) effective as it corresponds to the specialization, if apply. Meets with the mandatory trainings, such as: the Annual Compliance Plan, HR trainings, etc.
EEO Statement
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.
Notice
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating highly efficient and best-in-class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.
Qualifications
Provides strategic leadership to the daily operations of the Utilization Review Department. The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. Oversee the utilization reviews, organization determinations and appeals processes in accordance with established policies and procedures. The UR Director maintains full compliance with CMS regulatory standards for utilization reviews and appeals as outlined in the CMS Managed Care Manual, as well as local and national coverage determinations, the Puerto Rico Insurance Commissioner's Office, the Office of Personnel Management (OPM), and relevant accrediting bodies. Additionally, the UR Director must comply with URAC and NCQA standards. Ensure that denial and appeal letters are responded to in accordance with industry standards .
Responsibilities and essential duties:
EEO Statement
All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.
Notice
At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating highly efficient and best-in-class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.
Qualifications
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- Master's in social work, Psychology, Psychological Counseling, Mental Health Counseling or Psychiatric Nursing.
- Unrestricted valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling, Psychology, or Mental Health Counseling in the relevant jurisdiction.
- Professional associating membership ( colegiación ): Valid membership for Social Work and Psychiatric Nursing
- A minimum of five years' experience in the mental health field, working directly with patients or in clinical services supervision. Three or more years of experience in a leadership role specifically in the utilization review area or in mental health case management field .
- Require knowledge in Microsoft Office
- Fully Bilingual
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About Universal Health Services
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Universal Health Services (UHS) is a major player in the healthcare industry, based in King of Prussia, Pennsylvania, U.S. Founded in 1978, UHS offers hospital and healthcare services. Their diverse services range from acute care hospitals, behavioral health facilities and ambulatory centers nationwide. The company's mission of enhancing the health and well-being of their patients is reflected in their commitment to 'Helping Individuals Live Longer, Healthier and Happier Lives'. Universal Health Services' consistent growth and success in their industry have been recognized on numerous occasions, including being ranked amongst the Fortune 500 list of largest companies.
Industry
Health care and social assistance
Company size
10,000+ Employees
Headquarters location
King of Prussia, PA, US