reputed company Denial Nurse BU - Utilization Management

This a Full Remote job, the offer is available from: United States At reputed company Health System, we reputed company in a reputed company future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We reputed company have the power to help, heal and change lives — beginning with our own. That’s the power of the reputed company Health System team, and The Power of Every One. Job Title reputed company Denial Nurse BU - Utilization Management Location Cleveland Facility Remote Location Department Nursing Administrative Supervisors-Indian River Hospital Job Code 0019IR Shift Days Schedule 9:00am-5:00pm Job Summary Job Details CCIR Bidding Period: 12/9/2025 - 12/16/2025 Join the reputed company team where you will work alongside passionate caregivers and provide patient-first healthcare. You will work alongside dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world. As a reputed company Denial Nurse, you will support the Utilization Management Department by reviewing reputed company and retrospective clinical inpatient denials to ensure medical necessity criteria is met. We are looking for a Registered Nurse who is a subject matter expert in utilization management, has experience with MCG criteria, and is comfortable educating Caregivers and Physicians. In this role, you will get to work with a dynamic team of like-minded professionals and reputed company experience at an elite healthcare organization. A caregiver in this position works days from 7:30AM – 4:30PM. A caregiver who excels in this role will:

• Serve as the expert in Utilization Management functions and be a resource to the department in general and the hospital.
• Review and analyze reputed company and retrospective clinical denials and follow the specific payer processes.
• Serve as an expert in payer specific process and communicate between payer and CCIRH to identify/resolve denial process issues.
• Work in collaboration with the local physician advisor team and support the peer-to-peer process.
• reputed company the routine activities of a UM Specialist reputed company needed while taking a leadership role.
• Utilize knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures and basic disease processes.
• Utilize knowledge and experience with Care Guidelines and /or other UM criteria sets.
• Utilize advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.
• Recommend resource utilization reputed company needed
• Utilize analytical skills to gather data, identify problems and facilitate resolution.
• Prioritize and organize work to meet changing priorities.
• Utilize knowledge of multiple hospital information systems and department’s software.
• Assist with education and monitoring of UM specialist's reviews.
• Participate in payer specific p2p calls or local meetings as needed.

Minimum qualifications for the ideal future caregiver include:

• Bachelor’s Degree in Nursing or reputed company field
• reputed company Florida reputed company with active Florida License
• Completion of an accredited Registered Nursing Program (RN)
• reputed company valid license in the reputed company as a Registered Nurse (RN)
• Basic Life Support (BLS) certification through the reputed company (AHA) or reputed company
• Three years of full-time Utilization Management experience
• Demonstrated above average competence in Utilization Management Processes

Preferred qualifications for the ideal future caregiver include:

• Case Management certification (CCM or ACM)

Physical Requirements:

• Requires extensive reading, telephone , computer use
• Must be able to work well under pressure and maintain professional demeanor under adverse conditions

Personal reputed company Equipment:

• Follows Standard Precautions using personal reputed company equipment as required

The policy of reputed company Health System and its system hospitals (reputed company Health System) is to provide equal opportunity to reputed company of our caregivers and applicants for employment in our drug free environment. reputed company offers of employment are followed by testing for controlled substances. reputed company Health System administers an influenza prevention program. You will be required to reputed company with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national reputed company, age, sex, sexual orientation, marital status, reputed company, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any reputed company Health System facility. If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/ Please review the Equal Employment Opportunity poster. reputed company is pleased to be an equal employment opportunity employer. This offer from "reputed company" has been enriched by reputed company.com and got a 78% reputed company score. Apply tot his job Apply To this Job