Job Summary The Utilization Management Clinical Review nurse reviews and makes decisions about the ... Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and ...
Job Summary The Utilization Management Clinical Review nurse reviews and makes decisions about the ... Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and ...
The Utilization Management (UM) Clinical Reviewer is responsible for performing utilization review ... Refer complex or non-compliant cases to Physician Advisors or Medical Directors as appropriate
The Utilization Management (UM) Clinical Reviewer is responsible for performing utilization review ... Refer complex or non-compliant cases to Physician Advisors or Medical Directors as appropriate
... clinical care requirements and accreditation standards. This position is responsible for ... Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely ...
... clinical care requirements and accreditation standards. This position is responsible for ... Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely ...
... clinical care requirements and accreditation standards. This position is responsible for ... Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely ...
... clinical care requirements and accreditation standards. This position is responsible for ... Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely ...
... clinical care requirements and accreditation standards. This position is responsible for ... Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely ...
... clinical care requirements and accreditation standards. This position is responsible for ... Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely ...
Utilization Management Nurse
Phoenix, AZ · On-site +1
What You'll Bring to the Team: * 3+ years of clinical nursing experience. * Active, Unrestricted RN ... Utilization Management or Case Management Certification. Where You'll Work: This is a fully remote ...
Utilization Management Nurse
Phoenix, AZ · On-site +1
What You'll Bring to the Team: * 3+ years of clinical nursing experience. * Active, Unrestricted RN ... Utilization Management or Case Management Certification. Where You'll Work: This is a fully remote ...
Utilization Management Nurse
Phoenix, AZ · On-site
What You'll Bring to the Team: * 3+ years of clinical nursing experience. * Active, Unrestricted RN ... Utilization Management or Case Management Certification. Where You'll Work: This is a fully remote ...
Utilization Management Nurse
Phoenix, AZ · On-site
What You'll Bring to the Team: * 3+ years of clinical nursing experience. * Active, Unrestricted RN ... Utilization Management or Case Management Certification. Where You'll Work: This is a fully remote ...
Thorough knowledge of health care delivery, clinical quality assurance program metrics, UM, CM,CC ... Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely ...
Thorough knowledge of health care delivery, clinical quality assurance program metrics, UM, CM,CC ... Working Conditions Working Conditions: • Works non-regular hours, as required • Works remotely ...
Utilization Management Reviewer Requisition Number: R-000002878 Department Name: Supervisor ... Coordinates integration of regulatory, payer, and clinical standards to optimize patient outcomes ...
Utilization Management Reviewer Requisition Number: R-000002878 Department Name: Supervisor ... Coordinates integration of regulatory, payer, and clinical standards to optimize patient outcomes ...
Non-Clinical Case Manager
Phoenix, AZ · On-site
$35.52/hr
Non-Clinical Nurse Case Manager (RN II) Position Overview The Office of the State Surgeon Arizona ... The case management team will manage all active profiles. Currently there are approximately 969 ...
Non-Clinical Case Manager
Phoenix, AZ · On-site
$35.52/hr
Non-Clinical Nurse Case Manager (RN II) Position Overview The Office of the State Surgeon Arizona ... The case management team will manage all active profiles. Currently there are approximately 969 ...
Non-Clinical Case Manager
Phoenix, AZ · On-site
Job Title: Non-Clinical Nurse Case Manager (RN II) Position Overview The Office of the State ... The case management team will manage all active profiles. Currently there are approximately 969 ...
Non-Clinical Case Manager
Phoenix, AZ · On-site
Job Title: Non-Clinical Nurse Case Manager (RN II) Position Overview The Office of the State ... The case management team will manage all active profiles. Currently there are approximately 969 ...
RN - Utilization Review
Tuba City, AZ · On-site
$2.5K/wk
Stay current on the latest healthcare policies, clinical guidelines, and best practices for utilization management. * Participate in continuing education and training programs related to UR, case ...
RN - Utilization Review
Tuba City, AZ · On-site
$2.5K/wk
Stay current on the latest healthcare policies, clinical guidelines, and best practices for utilization management. * Participate in continuing education and training programs related to UR, case ...
PURPOSE STATEMENT: Proactively monitor utilization of services for patients to optimize ... Act as liaison between managed care organizations and the facility professional clinical staff.
PURPOSE STATEMENT: Proactively monitor utilization of services for patients to optimize ... Act as liaison between managed care organizations and the facility professional clinical staff.
Supervisor, Case Management
Phoenix, AZ · On-site
Advises non-clinical staff regarding Case Management support tasks. Supervisors are responsible for ... Thorough knowledge of TRICARE policies and procedures, Case Management, Utilization Management ...
Supervisor, Case Management
Phoenix, AZ · On-site
Advises non-clinical staff regarding Case Management support tasks. Supervisors are responsible for ... Thorough knowledge of TRICARE policies and procedures, Case Management, Utilization Management ...
... non-clinical checklists, and resolution of technical barriers. * Perform quality audits for Utilization Management activities and medical director determinations to evaluate consistency, accuracy ...
New
... non-clinical checklists, and resolution of technical barriers. * Perform quality audits for Utilization Management activities and medical director determinations to evaluate consistency, accuracy ...
New
Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Act as liaison between managed care organizations and the facility professional clinical staff.
Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Act as liaison between managed care organizations and the facility professional clinical staff.
Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Act as liaison between managed care organizations and the facility professional clinical staff.
Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Act as liaison between managed care organizations and the facility professional clinical staff.
Non-Clinical - Registrar
Tucson, AZ · On-site
Trauma Registrar The Trauma Registrar is responsible for collecting and managing trauma-related ... Free and unlimited continuing education units (CEUs) * 24/7 dedicated Care Line and clinical ...
Non-Clinical - Registrar
Tucson, AZ · On-site
Trauma Registrar The Trauma Registrar is responsible for collecting and managing trauma-related ... Free and unlimited continuing education units (CEUs) * 24/7 dedicated Care Line and clinical ...
Utilization Review Manager
Phoenix, AZ · On-site
... management including, but not limited to: utilization review, case documentation, payer ... A minimum of three (3) years direct clinical experience in a psychiatric or mental health setting.
Utilization Review Manager
Phoenix, AZ · On-site
... management including, but not limited to: utilization review, case documentation, payer ... A minimum of three (3) years direct clinical experience in a psychiatric or mental health setting.
... management including, but not limited to: utilization review, case documentation, payer ... A minimum of three (3) years direct clinical experience in a psychiatric or mental health setting.
... management including, but not limited to: utilization review, case documentation, payer ... A minimum of three (3) years direct clinical experience in a psychiatric or mental health setting.
Utilization Management Non Clinical information
What is the difference between Utilization Management Non Clinical vs Utilization Review Nurse?
| Aspect | Utilization Management Non Clinical | Utilization Review Nurse |
|---|---|---|
| Credentials | Certifications like CCM, RN (optional), but primarily non-clinical certifications | RN license, certifications such as CCM or CUC |
| Work Environment | Office-based, administrative setting, telecommuting options | Clinical settings, hospitals, or insurance companies, often with direct patient or provider interaction |
| Employer & Industry Usage | Health insurance companies, managed care organizations | Hospitals, insurance companies, healthcare providers |
| Search & Comparison Intent | Understanding non-clinical roles in utilization management | Clinical review roles involving direct patient care assessment |
Utilization Management Non Clinical roles focus on administrative, policy, and documentation tasks without direct patient care, while Utilization Review Nurses perform clinical assessments to determine care necessity. Both roles are essential in healthcare utilization but differ mainly in clinical involvement and required credentials.
Is utilization management a hard job?
Utilization Management Non Clinical roles involve reviewing healthcare services to ensure appropriate use of resources, which can be challenging due to the need for attention to detail, understanding of medical policies, and decision-making under time constraints. The job requires strong analytical skills, knowledge of healthcare guidelines, and often involves working with electronic health records and insurance policies.
What are popular job titles related to Utilization Management Non Clinical jobs in Arizona? For Utilization Management Non Clinical jobs in Arizona, the most frequently searched job titles are:
What job categories do people searching Utilization Management Non Clinical jobs in Arizona look for? The top searched job categories for Utilization Management Non Clinical jobs in Arizona are:
What cities in Arizona are hiring for Utilization Management Non Clinical jobs? Cities in Arizona with the most Utilization Management Non Clinical job openings:
Full-time
Medical, Dental, Vision, Life, Retirement, PTO
Re-posted 3 days ago
Job description
We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!
Job Summary
The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Education & Experience
Required:
• Active, unrestricted RN license
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 2+ years clinical experience
• 2+ years UM experience
• Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
• Demonstrates effective verbal and written communication skills
Preferred:
• 3+ years Medical / Surgical experience
• Behavioral Health experience
• 1 year TriWest or TRICARE experience
• Managed Care experience
Key Responsibilities
• Conducts prior authorization, continued stay, and referral management activities.
• Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria.
• Interprets information and makes decision whether authorizations align with the TriWest benefit program.
• Ensures timely reviews for requesting facilities and appropriate notification to parties.
• Contacts beneficiary and / or provider to obtain or clarify medical information as necessary.
• Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary.
• Prepares cases for Medical Director and Peer Review according to established policy.
• Refers potential quality issues and complaints to Clinical Quality Management.
• Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
• Maintain compliance with Federal, State and accreditation organizations.
• Performs other duties as assigned.
• Regular and reliable attendance is required.
Competencies
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.
Independent Thinking / Self-Initiative: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment
Technical Skills: Knowledge of TRICARE policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding
Working Conditions
Working Conditions:
• Ability to cover any work shift
• Ability to work overtime, if needed
• Onsite: Works within a standard office environment
• Remote: Private and secure work space and work station with high speed internet is required.
• Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone
Company Overview
Taking Care of Our Nation's Heroes.
It's Who We Are. It's What We Do.
Do you have a passion for serving those who served?
Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!
Our job is to make sure that America's heroes get connected to health care in the community.
At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.
Benefits
We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:
TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $88,000 - $93,000 per year.
Equal Employment Opportunity
TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.
Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.
Veterans, Reservists, Guardsmen and military family members are encouraged to apply!
Job Summary
The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources. Applies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. Utilizes clinical criteria and policy keys to complete review. Documents in the medical management information system. Prepares and presents more complex cases for Medical Director Review. Refer cases to Case Management and Disease Management as appropriate. Advises non-clinical staff on clinical and coding questions. Conducts pre-admission screening and assessments.
Education & Experience
Required:
• Active, unrestricted RN license
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 2+ years clinical experience
• 2+ years UM experience
• Proficient computer skills including Microsoft Office Suite (Teams, Word, Excel and outlook)
• Demonstrates effective verbal and written communication skills
Preferred:
• 3+ years Medical / Surgical experience
• Behavioral Health experience
• 1 year TriWest or TRICARE experience
• Managed Care experience
Key Responsibilities
• Conducts prior authorization, continued stay, and referral management activities.
• Assesses medical necessity by screening available information against established criteria, using InterQual Clinical Guidelines Policy Keys and Behavioral Health criteria.
• Interprets information and makes decision whether authorizations align with the TriWest benefit program.
• Ensures timely reviews for requesting facilities and appropriate notification to parties.
• Contacts beneficiary and / or provider to obtain or clarify medical information as necessary.
• Refers cases to Case Management, Care Coordination, or Disease Management for review as necessary.
• Prepares cases for Medical Director and Peer Review according to established policy.
• Refers potential quality issues and complaints to Clinical Quality Management.
• Notifies Internal Audit & Corporate Compliance department of cases for review of potential fraud.
• Maintain compliance with Federal, State and accreditation organizations.
• Performs other duties as assigned.
• Regular and reliable attendance is required.
Competencies
Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.
Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.
Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required.
Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position.
Independent Thinking / Self-Initiative: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.
High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.
Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented
Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment
Technical Skills: Knowledge of TRICARE policies and procedures, Utilization Management principles, Managed Care concepts, medical terminology, medical management system, InterQual criteria, working knowledge of medical coding
Working Conditions
Working Conditions:
• Ability to cover any work shift
• Ability to work overtime, if needed
• Onsite: Works within a standard office environment
• Remote: Private and secure work space and work station with high speed internet is required.
• Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone
Company Overview
Taking Care of Our Nation's Heroes.
It's Who We Are. It's What We Do.
Do you have a passion for serving those who served?
Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!
Our job is to make sure that America's heroes get connected to health care in the community.
At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.
Benefits
We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:
- Medical, Dental and Vision Coverage
- Paid time off
- 401(k) Retirement Savings Plan (with matching)
- Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
- Tuition reimbursement
- Paid volunteer time
TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $88,000 - $93,000 per year.
Equal Employment Opportunity
TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.