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60 Healthfirst Utilization Review Nurse Jobs Hiring Near You

Merrimack Health

Utilization Review Nurse

Methuen, MA · On-site

... they relate to utilization review and discharge planning and payer regulations. MINIMUM EDUCATION AND EXPERIENCE: Required: * Graduate of an accredited professional nursing school * Current ...

New

US Tech Solutions

Utilization Review Nurse

Chicago, IL · On-site

Do you have experience with Utilization Review? * Do you have an Active Registered Nurse License? About US Tech Solutions: US Tech Solutions is a global staff augmentation firm providing a wide range ...

AbsoluteCARE

Utilization Review Nurse

New Orleans, LA · On-site

The Utilization Review Nurse ensures appropriate utilization of health services by performing initial, concurrent and retrospective clinical case reviews. This role collaborates and communicates with ...

Merrimack Health

Utilization Review Nurse

Lawrence, MA · On-site

... they relate to utilization review and discharge planning and payer regulations. MINIMUM EDUCATION AND EXPERIENCE: Required: * Graduate of an accredited professional nursing school * Current ...

New

Shannon Health

Utilization Review Nurse

Big Spring, TX · On-site

Job Summary The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the ...

US Tech Solutions

Utilization Review Nurse

Chicago, IL · On-site

Do you have experience with Utilization Review? * Do you have an Active Registered Nurse License? About US Tech Solutions: US Tech Solutions is a global staff augmentation firm providing a wide range ...

US Tech Solutions

Utilization Review Nurse

Chicago, IL · On-site

Do you have experience with Utilization Review? * Do you have an Active Registered Nurse License? About US Tech Solutions: US Tech Solutions is a global staff augmentation firm providing a wide range ...

Merrimack Health

Utilization Review Nurse

Methuen, MA · On-site

... they relate to utilization review and discharge planning and payer regulations. MINIMUM EDUCATION AND EXPERIENCE: Required: * Graduate of an accredited professional nursing school * Current ...

New

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What other companies are hiring for Utilization Review Nurse jobs?

Infographic showing various Utilization Review Nurse job openings at Healthfirst in the United States as of August 2026, with employment types broken down into 99% Full Time, and 1% Part Time. Highlights an 66% Physical, 10% Hybrid, and 24% Remote job distribution.

Utilization Review Nurse

Search jobs on OhioMeansJobs

Chicago, IL • On-site

Contractor

Re-posted 20 days ago

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
  • Registered Nurse in state of residence
  • Must have prior authorization utilization experience
  • Experience with Medcompass
 
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
 
Questionnaire:
  • Do you have experience with Medcompass?
  • Do you have experience with Prior Authorization?
  • Do you have experience with Utilization Review?
  • Do you have an Active Registered Nurse License?
 
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.
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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