Atlanta, GA · Remote
$88.45K - $168.98K/yr
... utilization management, care transitions, long-term supports and services (LTSS), behavioral health, nurse advice line, and/or other special programs. Develops, implements and/or monitors ...
Atlanta, GA · Remote
$88.45K - $168.98K/yr
... utilization management, care transitions, long-term supports and services (LTSS), behavioral health, nurse advice line, and/or other special programs. Develops, implements and/or monitors ...
Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level ...
Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level ...
Atlanta, GA · On-site
Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level ...
Atlanta, GA · On-site
Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level ...
Atlanta, GA · On-site
Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Main responsibilities include but are not limited to: • Uses clinical/nursing skills to determine ...
Atlanta, GA · On-site
Provision of comprehensive Utilization Management, incorporating the strategies of cost containment ... Main responsibilities include but are not limited to: • Uses clinical/nursing skills to determine ...
Our nurses will be empathetic informative medical resources for our injured employees and they will ... management/utilization management required. Skills & Knowledge: * Knowledge of workers ...
Our nurses will be empathetic informative medical resources for our injured employees and they will ... management/utilization management required. Skills & Knowledge: * Knowledge of workers ...
Our nurses will be empathetic informative medical resources for our injured employees and they will ... management/utilization management required. Skills & Knowledge: * Knowledge of workers ...
Our nurses will be empathetic informative medical resources for our injured employees and they will ... management/utilization management required. Skills & Knowledge: * Knowledge of workers ...
$95.20K - $142.81K/yr
Demonstrates knowledge and competence in advanced practice clinical skills, including the nursing process and utilization management. Territories: * Henry County/SW Atlanta/Clayton * Cobb/Cherokee ...
$95.20K - $142.81K/yr
Demonstrates knowledge and competence in advanced practice clinical skills, including the nursing process and utilization management. Territories: * Henry County/SW Atlanta/Clayton * Cobb/Cherokee ...
$95.20K - $142.81K/yr
Demonstrates knowledge and competence in advanced practice clinical skills, including the nursing process and utilization management. Territories: * Henry County/SW Atlanta/Clayton * Cobb/Cherokee ...
$95.20K - $142.81K/yr
Demonstrates knowledge and competence in advanced practice clinical skills, including the nursing process and utilization management. Territories: * Henry County/SW Atlanta/Clayton * Cobb/Cherokee ...
Lawrenceville, GA · On-site +1
$49.50 - $60.25/hr
Collaborate with physicians, nurses, and medical directors during case reviews. * Track, document ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Lawrenceville, GA · On-site +1
$49.50 - $60.25/hr
Collaborate with physicians, nurses, and medical directors during case reviews. * Track, document ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Atlanta, GA · On-site +1
$55 - $67/hr
Collaborate with physicians, nurses, and medical directors during case reviews. * Track, document ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Atlanta, GA · On-site +1
$55 - $67/hr
Collaborate with physicians, nurses, and medical directors during case reviews. * Track, document ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
$57.62 - $66.79/hr
Duties and Responsibilities: 1. Under the direction of the Utilization Review Manager, supervises ... Case Management certification (CCM or ACM) preferred. Leadership experience preferred. Proven ...
$57.62 - $66.79/hr
Duties and Responsibilities: 1. Under the direction of the Utilization Review Manager, supervises ... Case Management certification (CCM or ACM) preferred. Leadership experience preferred. Proven ...
Lawrenceville, GA · Remote
$50.25 - $60.50/hr
Collaborate with physicians, nurses, and medical directors on complex cases. * Document outcomes in ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Lawrenceville, GA · Remote
$50.25 - $60.50/hr
Collaborate with physicians, nurses, and medical directors on complex cases. * Document outcomes in ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Atlanta, GA · Remote
$56 - $67.25/hr
Collaborate with physicians, nurses, and medical directors on complex cases. * Document outcomes in ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Atlanta, GA · Remote
$56 - $67.25/hr
Collaborate with physicians, nurses, and medical directors on complex cases. * Document outcomes in ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Atlanta, GA · On-site
$640 - $660/day
... utilization management, and discharge planning within an acute inpatient setting. This role serves ... Collaborates with nursing staff in assessing patient, family age-specific nursing needs and ...
Atlanta, GA · On-site
$640 - $660/day
... utilization management, and discharge planning within an acute inpatient setting. This role serves ... Collaborates with nursing staff in assessing patient, family age-specific nursing needs and ...
... utilization management, and discharge planning within an acute inpatient setting. This role serves ... Collaborates with nursing staff in assessing patient, family age-specific nursing needs and ...
Quick apply
... utilization management, and discharge planning within an acute inpatient setting. This role serves ... Collaborates with nursing staff in assessing patient, family age-specific nursing needs and ...
... utilization management review programs. The Manager will lead the nurse case management team to strategize with claim professionals in management of medical and disability exposure, delivering ...
... utilization management review programs. The Manager will lead the nurse case management team to strategize with claim professionals in management of medical and disability exposure, delivering ...
Atlanta, GA · On-site
$95.20K - $142.81K/yr
Demonstrates knowledge and competence in advanced practice clinical skills, including the nursing process and utilization management. Territories: * Henry County/SW Atlanta/Clayton * Cobb/Cherokee ...
Quick apply
Atlanta, GA · On-site
$95.20K - $142.81K/yr
Demonstrates knowledge and competence in advanced practice clinical skills, including the nursing process and utilization management. Territories: * Henry County/SW Atlanta/Clayton * Cobb/Cherokee ...
... utilization management review programs. The Manager will lead the nurse case management team to strategize with claim professionals in management of medical and disability exposure, delivering ...
... utilization management review programs. The Manager will lead the nurse case management team to strategize with claim professionals in management of medical and disability exposure, delivering ...
... utilization management review programs. The Manager will lead the nurse case management team to strategize with claim professionals in management of medical and disability exposure, delivering ...
... utilization management review programs. The Manager will lead the nurse case management team to strategize with claim professionals in management of medical and disability exposure, delivering ...
Atlanta, GA · On-site
$5.25K - $5.35K/wk
... utilization management, and discharge planning within an acute inpatient setting. This role serves ... Collaborates with nursing staff in assessing patient, family age-specific nursing needs and ...
Quick apply
Atlanta, GA · On-site
$5.25K - $5.35K/wk
... utilization management, and discharge planning within an acute inpatient setting. This role serves ... Collaborates with nursing staff in assessing patient, family age-specific nursing needs and ...
$38.1K - $49.1K
15% of jobs
$49.1K - $60.1K
8% of jobs
$61.7K is the 25th percentile. Wages below this are outliers.
$60.1K - $71.1K
15% of jobs
The median wage is $78K / yr.
$71.1K - $82.1K
20% of jobs
$82.1K - $93.1K
11% of jobs
$98.6K is the 75th percentile. Wages above this are outliers.
$93.1K - $104.1K
13% of jobs
$104.1K - $115.1K
5% of jobs
$115.1K - $126.1K
3% of jobs
$126.1K - $137.1K
4% of jobs
$137.1K - $148.1K
3% of jobs
$148.1K - $159.1K
3% of jobs
$38.1K
$87.4K
$159.1K
A utilization management nurse ensures that healthcare services are administered appropriately. Their job responsibilities include working in a hospital, health practice, or other clinical setting reviewing patient clinical records, drafting clinical appeals, and overseeing staff members. The qualifications for a utilization management nurse include a nursing degree and a registered nursing license. Most people in this job also have career experience in case management and utilization review.
| Aspect | Utilization Management Nurse | Case Manager |
|---|---|---|
| Credentials | RN license, certifications in utilization review | RN license, case management certification often preferred |
| Work Environment | Insurance companies, healthcare organizations, utilization review departments | Hospitals, community health agencies, insurance companies |
| Primary Focus | Reviewing medical necessity and appropriateness of services | Coordinating patient care and discharge planning |
Utilization Management Nurses primarily focus on reviewing medical necessity and approving healthcare services, while Case Managers coordinate patient care and facilitate discharge planning. Both roles require RN licensure and work within healthcare or insurance settings, but their core responsibilities differ in scope and focus.
$88.45K - $168.98K/yr
Full-time
Posted 5 days ago
8.0
Based on 191 frontline employees who took The Breakroom Quiz
144th of 259 rated insurance
JOB DESCRIPTION
Leads and directs a multidisciplinary team of healthcare services professionals in some or all of the following functions: utilization management, care management, behavioral health and other programs. Leads team responsible for assessing, facilitating, planning and coordinating integrated delivery of care across the continuum. Participates with senior leadership to establish strategic plans and objectives. Contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
Directs and oversee one or more of the following key health care services functions: care management, utilization management, care transitions, long-term supports and services (LTSS), behavioral health, nurse advice line, and/or other special programs.
Develops, implements and/or monitors standardized protocols for clinical and non-clinical team activities to facilitate integrated proactive care coordination/care review and management.
Develops and promotes interdepartmental integration and collaboration to enhance clinical services.
Collaborates with and keeps healthcare services senior leadership informed of operational issues, staffing, resources, system and program needs and presents solutions/action plans for issues.
Facilitates and participates in committees, task forces, work groups and multidisciplinary teams as needed to promote a standardized enterprise-wide approach to healthcare services programs.
Ensures monthly auditing occurs with appropriate follow-up.
Engages in clinical training activities and outcomes.
Develops and mentors direct reporting healthcare services leadership.
Local travel may be required (based upon state/contractual requirements).
Required Qualifications
At least 8 years of health care experience, and at least 5 years of managed care experienced in one or more of the following areas: utilization management, care management, care transitions, behavioral health, long-term services and supports (LTSS), or equivalent combination of relevant education and experience.
At least 3 years of health care management/leadership required.
Registered Nurse (RN), Licensed Vocational Nurse (LVN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Clinical Counselor (LPCC), or Licensed Master of Social Work (LMSW). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
Experience working within applicable state, federal, and third-party regulations.
Ability to manage conflict and lead through change.
Operational and process improvement experience.
Ability to work cross-collaboratively across a highly matrixed organization.
Ability to prioritize and manage multiple deadlines.
Excellent organizational, problem-solving and critical-thinking skills.
Strong written and verbal communication skills.
Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
Registered Nurse (RN). License must be active and unrestricted in state of practice.
Certified Case Manager (CCM), Certified Professional in Health Care Management certification (CPHM), Certified Professional in Health Care Quality (CPHQ) or other health care or management certification.
Medicaid/Medicare population experience.
Clinical experience.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Pay Range: $88,453 - $168,981 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others.
Health care and social assistance
10,000+ Employees
Long Beach, CA, US
1980
