RN Utilization Review remote - MediGold Health Plan

Mount Carmel Health System; Columbus (OH); Remote; USD 70,000 - 85,000; Full time

Job summary

Join a leading health system as an RN Utilization Review professional, responsible for coordinating care and collaborating with medical providers to ensure appropriate service utilization. This full-time role offers the opportunity to leverage your nursing expertise in a challenging environment dedicated to exceptional patient care and operational excellence.

Benefits

Competitive compensation

Comprehensive benefits

Generous paid time off

Tuition reimbursement

Relocation assistance

Qualifications

• Minimum of 5-7 years of clinical nursing experience with at least 2 years in utilization review or case management.
• Current license to practice as a Registered Nurse in their home state.

Responsibilities

• Coordinate medical care provided to Plan members with Providers and families.
• Develop and review the Plan's UM Program.
• Document and communicate identified quality concerns.

Skills

Assessment

Documentation

Medical Analysis

Education

Associate or Bachelor's Degree in Nursing

Job description

RN Utilization Review remote - MediGold Health Plan

Join to apply for the RN Utilization Review remote - MediGold Health Plan role at Mount Carmel Health System

RN Utilization Review remote - MediGold Health Plan

Join to apply for the RN Utilization Review remote - MediGold Health Plan role at Mount Carmel Health System

Why MediGold?

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

Employment Type

Full time

Shift

Description:

Why MediGold?

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

Position Purpose

RN Utilization Review MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member's family and other resources as appropriate. Assist in the development of the Plan's UM Program and the review of the Plan's Medical Management Plan.

What You Will Do

• Participates in designated committees and task forces according to the UM Program and at the direction of the Sr. Director of Medical Management.
• Coordinates with the utilization review, case management, discharge planning staff within network facilities.
• Coordinates with Medical Director/Associate Medical Directors on case-specific issues.
• Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues.
• Documents and communicates to QM staff appropriately all identified quality concerns related to Members.
• All other duties as assigned.
  
  

Minimum Qualifications

• Education: Associate or Bachelor's Degree in Nursing
• Licensure / Certification: Current license to practice as a Registered Nurse in their home state or hold a compact nursing license.
• Experience: Minimum of 5-7 years of clinical nursing experience with at least 2 years’ experience in utilization review or case management. Nursing experience in an HMO insurance setting preferred· Demonstrated ability to analyze, summarize and concisely report medical utilization and medical chart audit results.
• Ability to compare approved criteria with clinical information to determine appropriateness of service and to document all related information according to department policies and procedures.
• Conducts claim review as required for appropriate claims processing
  
  

Position Highlights And Benefits

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• Relocation assistance (geographic and position restrictions apply).
• Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing.
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.
  
  

Ministry/Facility Information

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

00595930

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

Referrals increase your chances of interviewing at Mount Carmel Health System by 2x

Get notified about new Registered Nurse jobs in Columbus, OH.

2 MedSurg RN openings at Arthur G. James Cancer Hospital for $2283.04 gross weekly

Columbus, OH $1,661.52-$1,661.52 1 week ago

Columbus, OH $1,758.00-$1,911.00 2 days ago

Columbus, OH $1,661.52-$1,661.52 2 days ago

Columbus, OH $1,661.52-$1,661.52 3 days ago

Columbus, OH $1,661.52-$1,661.52 1 week ago

Columbus, OH $1,661.52-$1,661.52 1 week ago

1 MedSurg RN opening at Arthur G. James Cancer Hospital for $2283.04 gross weekly

Columbus, OH $2,215.08-$2,215.08 1 day ago

Travel Nurse - RN - ICU - Intensive Care Unit

Columbus, OH $2,197.00-$2,197.00 1 week ago

Columbus, OH $1,934.33-$1,934.33 1 week ago

Outpatient Registered Nurse, Cardiology (Doctors)

Staff RN - ED Main Campus (Experienced RNs)

Upper Arlington, OH $70,000.00-$80,000.00 1 day ago

Columbus, OH $2,143.20-$2,143.20 1 week ago

Columbus, OH $2,203.28-$2,203.28 2 days ago

Travel PCU Registered Nurse - $2,197 per week

Columbus, OH $2,196.00-$2,196.00 1 week ago

Travel PCU Registered Nurse - $2,056 per week

Columbus, OH $2,055.32-$2,055.32 1 week ago

Columbus, OH $1,854.31-$1,854.31 2 days ago

Travel PCU Registered Nurse - $1,945 per week

Columbus, OH $1,944.00-$1,944.00 1 week ago

Columbus, OH $1,854.31-$1,854.31 1 week ago

Columbus, OH $1,966.14-$1,966.14 1 week ago

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.