27 utilization management nurse jobs found

Utilization Management Nurse Location : Onsite in Dubuque, IA. Also accepting remote applicants. We are looking for a nurse just like you - a nurse that thrives in a fast-paced environment, enjoys making a difference for patients, and prefers working in a professional office setting with daytime office hours and weekends/holidays off. This position is responsible for working telephonically with providers to evaluate and pre-certify requests such as hospital stays, outpatient surgeries, outpatient tests, care, etc. Review requests and match up to an evidence-based guideline to ensure proper care and ensure the right service is happening at the right time and is medically necessary. In this position you will be handling multiple provider phone calls at any given time and need to be able to handle a very fast paced environment. You will also work closely with participants for referrals to case management and condition management services according to referral criteria and...

Utilization Management Nurse Location : Onsite in Dubuque, IA. Also accepting remote applicants. We are looking for a nurse just like you - a nurse that thrives in a fast-paced environment, enjoys making a difference for patients, and prefers working in a professional office setting with daytime office hours and weekends/holidays off. This position is responsible for working telephonically with providers to evaluate and pre-certify requests such as hospital stays, outpatient surgeries, outpatient tests, care, etc. Review requests and match up to an evidence-based guideline to ensure proper care and ensure the right service is happening at the right time and is medically necessary. In this position you will be handling multiple provider phone calls at any given time and need to be able to handle a very fast paced environment. You will also work closely with participants for referrals to case management and condition management services according to referral criteria and...

Utilization Management Nurse Location : Onsite in Dubuque, IA. Also accepting remote applicants. We are looking for a nurse just like you - a nurse that thrives in a fast-paced environment, enjoys making a difference for patients, and prefers working in a professional office setting with daytime office hours and weekends/holidays off. This position is responsible for working telephonically with providers to evaluate and pre-certify requests such as hospital stays, outpatient surgeries, outpatient tests, care, etc. Review requests and match up to an evidence-based guideline to ensure proper care and ensure the right service is happening at the right time and is medically necessary. In this position you will be handling multiple provider phone calls at any given time and need to be able to handle a very fast paced environment. You will also work closely with participants for referrals to case management and condition management services according to referral criteria and...

Responsible for planning, coordinating and supervising assigned department(s)/area(s) to ensure an efficient and cost-effective area of responsibility in accordance with established corporate and departmental policies and procedures.   Supervise and promote the professional development of assigned staff through selection, development, and exploration of more effective methods of managing projects and time. Research (internally and externally), initiate, and plan strategic changes in assigned department(s)/area(s) to optimize technologies and personnel. Recommend and assist in acquisition of technology and other tools or equipment and resources to optimize departmental performance and output. Prioritize and assign work to employees and initiate corrective measures to resolve problems, including scheduling or adjusting overtime requirements as necessary. Interface with diverse levels of internal and external personnel to develop and maintain effective rapport and to resolve...

Coordination of all activity associated with the development and maintenance of medical policy and benefit interpretation in accordance with BCN certificates, riders, waivers, statewide policies and with BCBSM policies and procedures.  Investigation of new procedures, technology, drugs and devices.  Maintenance of clinical documentation related to new technologies and treatment modalities, including BCN's position of coverage of these items/services/treatments.  Communication to and education of team members, including physician advisors regarding new technologies, treatment modalities, drugs and devices with an emphasis/focus on BCN's policy and benefit determination. Coordination of all requests related to solid organ transplants (other than kidney, skin and cornea) and for bone marrow transplants, as well as for services that are potentially experimental or investigational. Proactively identify and evaluate documentation on new treatments and technologies for potential...

A Workers' Compensation Nurse Case Manager coordinates and manages the medical care of injured employees throughout the workers' compensation claim process. Responsibilities include evaluating medical needs, assessing treatment progress, identifying barriers to recovery, educating stakeholders, and ensuring care is delivered in accordance with workers' compensation regulations and best practices. The official NJM job title is Medical Management Coordinator II/Telephonic Nurse Case Manager. The position requires the nurse to work and communicate with other members of the Medical Management team in addition to the Workers' Compensation (WC) Claims team, WC Claims Supervisors, and other team members. Essential Duties and Responsibilities: Demonstrate knowledge, skills, and competency in the application of case management standards of practice. Develop and provide ongoing support of the rehabilitation plan through comprehensive assessment, planning, implementation, and...

A career at Auto-Owners is challenging and rewarding.  Our group of caring associates create financial security by helping individuals and businesses make a new start when a loss occurs. Job Description We offer a merit-based work-from-home program based on job responsibilities. After initial training in-person, this specific role could have the flexibility to work from home up to 3 days per week. Auto-Owners Insurance, a top-rated insurance carrier, is seeking motivated nursing professional to join our team. The position requires the person to: Use the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the claimant’s health across the care continuum. Coordinate care delivery and support among claimant support systems, including providers, community-based agencies, and family Collaborate with claims associates to provide medical expertise in the investigation, evaluation, and appropriate resolution of...

If you’re passionate about helping people protect what matters most to them at a Fortune 100 company with nearly $70 billion in annual sales, as well as innovating and simplifying processes and operations to provide the best customer value, then Nationwide’s Property and Casualty team could be the place for you! At Nationwide®, “on your side” goes beyond just words. Our customers and partners are at the center of everything we do and we’re looking for associates who are passionate about delivering extraordinary care. #LI-KP1 #LI-Remote Job Description Summary Do you have a strong desire to provide prompt, courteous and fair service to customers? Are you a skilled investigator, negotiator and communicator? If you thrive in an environment where you can problem-solve workers’ compensation claims resolution, while following processes that provide fair resolution, customer satisfaction and cost management, then we want to hear from you! As a Claims Specialist, you’ll...

Why Arbella? At Arbella, we’re focused on people. We work hard to attract and retain the best. That means providing a great work environment, encouraging work/life balance, offering flexible work arrangements, and competitive, industry-leading salaries and benefits packages. We invest in our employees and encourage them to grow so that we, too, can grow as a company. Other perks include: • On-site gym and fitness classes and one-on-one personal training • On-site nurse, nutritional counseling, and mental health resources • Full-service cafeterias • Free shuttle service to Quincy Adams T Station • Tuition assistance programs • Opportunities to get involved: Arbella Activities Committee, Diversity and Inclusion Council, and more • A company committed to community: volunteer opportunities, employee-led community efforts, and the Arbella Insurance Foundation • Robust training, mentorship, and professional/personal development programs • Colleagues who...

Location: Bloomington, Minnesota (Hybrid) | Full-Time Pay: $74,500.00 to $104,295.00; annual salary.  Ranked #8 Top Workplace  – Midsize Employer, MN About the Role: At SFM, doing the right thing guides everything we do and gives our employees the chance to make a real difference in people’s lives. As a Nurse Case Manager, you will serve as a medical resource and educator, helping manage workers’ compensation claims. Working primarily by phone, you will provide high-quality service to injured workers and policyholders, managing the medical side of each claim and promoting a safe, timely return to work. You will partner with claims representatives as part of a multidisciplinary Business Team, using your medical expertise to help resolve medical and claim issues in a cost-effective way. You will also promote effective case management that follows medical best practice guidelines and state laws and regulations. Delivering excellent customer service to everyone involved...

Crum & Forster Company Overview Crum & Forster (C&F) provides market leading property & casualty, accident & health, specialty and standard commercial lines insurance solutions. A true underwriting company, we have a 200-year history of helping our customers manage risk with laser-focused expertise, integrity and discipline. Our people are empowered to make decisions and problem-solve with you smartly and swiftly. Our annual gross written premium is 6.2 billion. C&F enjoys a financial strength rating of "A+" (Superior) by AM Best.   Our most valuable asset is our people. We have 3000 employees, and locations throughout the United States and India. With our employee-first focus, the Company is consistently recognized as a great place to work, earning multiple workplace and wellness awards, including the Great Place to Work® Award, Fortune 100 Best Companies to Work For, Fortune Best Workplaces for Parents, Fortune Best...

Overview AmTrust Financial Services, a fast growing commercial insurance company, has a need for a Telephonic Medical Case Manager, RN.   PRIMARY PURPOSE: To provide comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider and employer.  Our nurses will be empathetic informative medical resources for our injured employees and they will partner with our adjusters to develop a personalized holistic approach for each claim.  These responsibilities may include utilization review, pharmacy oversight and care coordination.    This position is remote in Florida or Georgia. Responsibilities Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered. Perform Utilization Review activities prospectively, concurrently or...

Overview AmTrust Financial Services, a fast growing commercial insurance company, has a need for a Telephonic Medical Case Manager, RN.   PRIMARY PURPOSE:  To provide comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider and employer.  Our nurses will be empathetic informative medical resources for our injured employees and they will partner with our adjusters to develop a personalized holistic approach for each claim.  These responsibilities may include utilization review, pharmacy oversight and care coordination.   This position is remote in Utah! Responsibilities Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered. Perform Utilization Review activities prospectively, concurrently or retrospectively in...

Overview AmTrust Financial Services, a fast-growing commercial insurance company, has an opportunity for a Manager, RN Branch Manager of Telephonic Case Management for Workers Compensation where your clinical talent and leadership abilities contribute to our competitive edge.    PRIMARY PURPOSE: The RN Branch Manager for telephonic case management services will oversee operations as well as a team of experienced worker’s compensation nurse case managers. The ideal candidate will have a minimum of three (3) or more years’ experience overseeing a nursing claims management program as well as in-depth understanding of worker’s compensation injury claims 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 quality telephonic case management to proactively drive best in class outcomes including appropriate medical...

Overview AmTrust Financial Services, a fast-growing commercial insurance company, has an opportunity for a Manager, RN Branch Manager of Telephonic Case Management for Workers Compensation where your clinical talent and leadership abilities contribute to our competitive edge.    PRIMARY PURPOSE: The RN Branch Manager for telephonic case management services will oversee operations as well as a team of experienced worker’s compensation nurse case managers. The ideal candidate will have a minimum of three (3) or more years’ experience overseeing a nursing claims management program as well as in-depth understanding of worker’s compensation injury claims 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 quality telephonic case management to proactively drive best in class outcomes including appropriate medical...

Be Here. Be Great. Working for a leader in the insurance industry means opportunity for you. Great American Insurance Group’s member companies are subsidiaries of American Financial Group. We combine a "small company" culture where your ideas will be heard with "big company" expertise to help you succeed. With over 35 specialty property and casualty operations, there are always opportunities here to learn and grow. At Great American, we value and recognize the benefits derived when people with different backgrounds and experiences work together to achieve business results. Our goal is to create a workplace where all employees feel included, empowered, and enabled to perform at their best. For over 50 years, Republic Indemnity has been a trusted partner for businesses across the western U.S., helping them effectively manage their workers' compensation costs. Our headquarters in Woodland Hills, California, along with an additional office in San Francisco, to serve a hub for our...

Position Summary: The Clinical Health Navigator, RN serves as a trusted clinical resource for employees and their families enrolled in self-funded health plans, helping them navigate complex healthcare decisions and access high-quality, appropriate, and cost-effective care. The Clinical Health Navigator builds ongoing, trust-based relationships with members and provides personalized guidance when healthcare becomes difficult to understand or navigate. The Navigator applies clinical knowledge, healthcare-system expertise, and benefits awareness to help members make informed decisions and overcome barriers to care. Essential Tasks: Guide members through complex healthcare moments.  Build direct, trust-based relationships with employees and their families navigating serious diagnoses, high-cost treatments, complex care journeys, or difficult healthcare decisions. Help members understand their clinical situation, available options, and benefits well enough to make informed...

The Doctors Company Patient Safety team has an opportunity for a Patient Safety Specialist. This role is a full-time on a hybrid basis (2x per week in-office). Position Mission Under general supervision, reviews claim files and medical records and then enters data into internal and external systems. This position will also assist the Patient Safety Department with research and writing articles.  Contacts are employees at all levels, external partners and vendors.  Qualifications Baccalaureate or advanced degree in nursing, healthcare, health sciences, patient safety, risk management, health information management, data science, or a related field. Three (3) or more years of experience in one or more of the following areas: healthcare, medical malpractice claims, patient safety, healthcare risk management, quality improvement, clinical review, clinical data analysis, claims analytics, healthcare data analysis, or healthcare data science. The ability to work...

A career at Auto-Owners is challenging and rewarding.  Our group of caring associates create financial security by helping individuals and businesses make a new start when a loss occurs. Job Description We offer a merit-based work-from-home program based on job responsibilities. After initial training in-person, this specific role could have the flexibility to work from home up to 3 days per week. Auto-Owners Insurance, a top-rated insurance carrier, is seeking motivated nursing professional to join our team. The position requires the person to: ·        Collaborate with claims associates to provide medical expertise in the investigation, evaluation, and appropriate resolution of injury claims including workers’ compensation, personal injury protection (no fault), and liability. ·        Evaluate medical records for relatedness to the injury and appropriate utilization of medical treatment and services. ·        Prepare and deliver trainings to claims...

Utilization Management Assistant Location : Onsite in Dubuque, IA. Also accepting remote applicants. Are you passionate about patient care and thrive in a fast-paced, professional environment? We are seeking a dedicated Utilization Management Assistant to join our healthcare team. We are looking for individuals with experience in a medical setting, including but not limited to a receptionist, scheduler, insurance verification, LPN, CNA, Medical Assistants, or individuals with a background in customer service who are looking to make a meaningful impact behind the scenes. If you are looking to get into a professional office setting with daytime office hours and weekends/holidays off , this is the role for you!  The Utilization Management Assistant answers first level calls in Utilization Review for our Health & Wellness participants. They will evaluate certification requests by reviewing the group specific requirements and will also triage the call to determine if a...