Providence, RI · On-site
... utilization management review. · MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG. · MUST HAVE 6 months of Prior Authorization. Education: · Active and unrestricted ...
Providence, RI · On-site
... utilization management review. · MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG. · MUST HAVE 6 months of Prior Authorization. Education: · Active and unrestricted ...
Drug Utilization Review Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug Utilization Review (DUR) Pharmacist to support ...
Drug Utilization Review Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug Utilization Review (DUR) Pharmacist to support ...
Drug Utilization Review Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug Utilization Review (DUR) Pharmacist to support ...
Drug Utilization Review Pharmacist - Ensure Safe and Effective Use of Medications A confidential managed care organization is seeking a skilled Drug Utilization Review (DUR) Pharmacist to support ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management, reviewing intake assessments, verifying clinical appropriateness for services, coordinating ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management, reviewing intake assessments, verifying clinical appropriateness for services, coordinating ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management, reviewing intake assessments, verifying clinical appropriateness for services, coordinating ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management, reviewing intake assessments, verifying clinical appropriateness for services, coordinating ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management, reviewing intake assessments, verifying clinical appropriateness for services, coordinating ...
The Behavioral Health Intake and Utilization Review Coordinator is responsible for bed management, reviewing intake assessments, verifying clinical appropriateness for services, coordinating ...
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
North Providence, RI · On-site
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
North Providence, RI · On-site
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
North Providence, RI · On-site
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
North Providence, RI · On-site
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
Or, 4 years of Behavioral Health utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical. Description Location: This position is full-time (40 hours/week) Monday ...
Or, 4 years of Behavioral Health utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical. Description Location: This position is full-time (40 hours/week) Monday ...
Pawtucket, RI · On-site
Working collaboratively across an integrated team of caseworkers, behavioral assistants, and clinicians, the Senior Caseworker develops treatment goals, conducts evaluation/utilization reviews ...
Pawtucket, RI · On-site
Working collaboratively across an integrated team of caseworkers, behavioral assistants, and clinicians, the Senior Caseworker develops treatment goals, conducts evaluation/utilization reviews ...
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
Utilization Review; Resource Management; Continuum of Care Management (Discharge planning) and Clinical Documentation Management. Collects data via utilization with Care Port to enhance the quality ...
Providence, RI · On-site
Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager
New
Providence, RI · On-site
Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager
New
Providence, RI · On-site
Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager
Providence, RI · On-site
Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager
Providence, RI · On-site
$95 - $96/hr
Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as ...
Providence, RI · On-site
$95 - $96/hr
Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as ...
Providence, RI · On-site
Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager
Providence, RI · On-site
Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager
Providence, RI · On-site
Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager
Providence, RI · On-site
Utilization Review * Point of Entry and Emergency Department Duties, when applicable per assignment * Utilization Review for POE/ED RN Case Manager * Resource Allocation for POE/ED RN Case Manager
Providence, RI · On-site
$95 - $100/hr
Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as ...
Providence, RI · On-site
$95 - $100/hr
Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as ...
Providence, RI · On-site
$95 - $109/hr
Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as ...
Providence, RI · On-site
$95 - $109/hr
Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as ...
$20.95 - $25.19
2% of jobs
$25.19 - $29.43
9% of jobs
$32.33 is the 25th percentile. Wages below this are outliers.
$29.43 - $33.66
21% of jobs
The median wage is $37.09 / hr.
$33.66 - $37.90
23% of jobs
$37.90 - $42.14
13% of jobs
$45.43 is the 75th percentile. Wages above this are outliers.
$42.14 - $46.38
10% of jobs
$46.38 - $50.61
8% of jobs
$50.61 - $54.85
5% of jobs
$54.85 - $59.09
5% of jobs
$59.09 - $63.33
2% of jobs
$63.33 - $67.56
2% of jobs
$20
$41
$67
A typical day in Utilization Review involves reviewing patient medical records, evaluating the necessity and appropriateness of proposed treatments or services, and documenting recommendations based on clinical criteria and insurance policies. Utilization Review specialists often collaborate closely with physicians, nurses, and insurance representatives to gather additional information and clarify cases. While much of the role is desk-based and may include remote work options, it requires regular communication with both clinical and administrative teams. This position offers variety and challenge, as no two cases are exactly alike, and there are often opportunities to advance into supervisory or quality improvement roles within the department.
A Utilization Review (UR) job involves assessing the medical necessity, efficiency, and appropriateness of healthcare services. UR professionals, often nurses or healthcare specialists, review patient records, insurance claims, and treatment plans to ensure they meet industry standards and payer requirements. They work with healthcare providers, insurance companies, and regulatory agencies to optimize care while controlling costs. Their goal is to balance quality patient care with cost-effective resource utilization.
To thrive in Utilization Review, professionals typically need a background in nursing or healthcare, strong clinical assessment capabilities, and a thorough understanding of medical guidelines and insurance regulations. Familiarity with electronic medical records (EMR) systems and utilization management software, and often certification such as Certified Utilization Review Specialist (CURN), are important. Excellent critical thinking, attention to detail, and strong communication skills enable effective case evaluation and collaboration with healthcare teams. These skills and qualifications ensure objective, accurate decisions that support cost-effective, quality patient care within compliance standards.
Please note: Actual location may vary., RI
Contract
Job Description:
· Participates in the development and ongoing implementation of QM Work Plan activities.
· Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives
Responsibilities:
· Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations.
· Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
· Data gathering requires navigation through multiple system applications.
· Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
· Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
· Responsible for the review and evaluation of clinical information and documentation.
· Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
· Works Potential Quality of Care cases across all lines of business (Commercial and Medicare).
· Independently coordinates the clinical resolution with internal/external clinician support as required.
· Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data
· Prepares and completes QM documents based on interpretation and application of business requirements
· Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements
· Assists in the development and implementation of QM projects and activities
· Accountable for completing and implementation of QM Work Plan Activities
Experience:
· 3+ years of experience as an RN
· 1+ years of inpatient hospital experience
· Registered Nurse in state of residence
· Must have prior authorization utilization experience
· Able to work in multiple IT platforms/systems
Skills:
· MUST HAVE MEDCOMPASS or ASSURECARE exp.
· MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge.
· MUST HAVE UM experience, inpatient utilization management review.
· MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG.
· MUST HAVE 6 months of Prior Authorization.
Education:
· Active and unrestricted RN licensure in state of residence
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com (http://www.ustechsolutionsinc.com/) .
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions.
It services
1,001 - 5,000 Employees
Jersey City, NJ, US
2000
