Nurse

• Complete clinical reviews for appropriateness, medical necessity, and quality
• Apply standardized clinical review criteria to determine medical necessity for service authorization requests
• Refer requests to an appropriate physician peer reviewer when criteria are not clearly met
• Perform pre-service, concurrent, and retrospective reviews
• Process authorization requests for inpatient admissions, rehabilitation, skilled nursing, home care/home infusion, and outpatient or inpatient services
• Document timely decisions and actions in the managed care information system (MCIS)
• Meet contractual timelines for review activities
• Communicate and interact with providers and internal/external partners to coordinate utilization-management activities
• Communicate determinations to providers according to established processes
• Participate in required staff meetings and complex case rounds
• Perform discharge planning to support safe and timely enrollee discharges
• Complete Inter-rater Reliability training, exams, and testing
• Follow utilization-management workflow processes
• Participate in a weekend and holiday coverage rotation
• Perform other duties supporting utilization-management functions

Physical Health Registered Nurse reviewing medical necessity for Vaya Health members

Physical Health Registered Nurse – Vaya

Physical Health Registered Nurse conducting utilization-management reviews for Vaya Health, a behavioral and physical health organization. Determining medical necessity, coordinating authorizations, and supporting safe member discharges.

• Complete clinical reviews for appropriateness, medical necessity, and quality
• Apply standardized clinical review criteria to service authorization requests
• Refer requests to physician peer reviewers when medical necessity criteria are not clearly met
• Review pre-service, concurrent, and retrospective requests
• Process authorization requests for inpatient, rehabilitation, skilled nursing, home care/home infusion, outpatient, and inpatient services
• Document timely decisions and actions in the managed care information system (MCIS)
• Meet contractual timelines for review activities
• Communicate with providers and internal and external partners to coordinate utilization management activities
• Communicate determinations to providers according to established processes
• Participate in staff meetings and complex case rounds
• Perform discharge planning for safe and timely enrollee discharges
• Complete utilization management workflow processes and other assigned UM duties
• Participate in weekend and holiday coverage rotations

Registered Nurse conducting utilization-management reviews for Vaya Health members

Physical Health Registered Nurse – Remote

Registered Nurse conducting utilization-management reviews for Vaya Health members. Processing service authorizations, coordinating provider determinations, and supporting safe discharge planning.

• Provide telephonic clinical assessment, health education and utilization management services across the life span
• Care coordination for patients, including prior authorization; identifying and seeking solutions for barriers to care
• Provide telephonic triage for patients seeking care with multiple complaints
• Assessment and provision of care using telecommunication devices
• Application of the nursing process in telehealth care
• Delivery of culturally sensitive, age-specific care to identified populations
• Use of clinical decision support tools
• Provide effective therapeutic communication, counsel and crisis management
• Handle multiple in bound calls and ability to complete out-bound calls
• Other duties as assigned.

Virtual RN providing telephonic clinical assessment for general care

Nurse, Virtual RN

Virtual RN providing telephonic clinical assessment and health education in a community-based setting for Westside Family Healthcare. Participate in care coordination and telehealth services for diverse patient needs.

• Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
• Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
• Collaborates with healthcare partners to ensure timely review of services and care.
• Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
• Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
• Triages and prioritizes cases and other assigned duties to meet required turnaround times.
• Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
• Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
• Duties as assigned.

Utilization Management Nurse performing clinical reviews for health services.

Utilization Management Nurse

Utilization Management Nurse providing evaluations of medical necessity for healthcare services. Collaborates with healthcare partners and handles clinical documentation remotely.

• Administer neurotoxin injections (Botox/Dysport) and dermal fillers per established protocols
• Perform medical-grade facials, chemical peels, and skin rejuvenation treatments
• Conduct thorough client consultations, skin assessments, and treatment planning
• Administer IV hydration, vitamin injections, and wellness therapies as needed
• Educate clients on treatment options, aftercare, and maintenance plans
• Maintain accurate, compliant documentation for all services rendered
• Deliver a polished, professional client experience consistent with NPOC's brand standards

Aesthetic RN providing Botox, facials, and wellness services at NPOC Wellness & Hydration

Aesthetic Nurse, RN

Aesthetic Registered Nurse providing Botox, facials, and wellness services at NPOC Wellness & Hydration. Ensuring high-quality client experience and clinical precision in a boutique environment.

Nurse jobs in Maryland

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Physical Health Registered Nurse – Vaya

Physical Health Registered Nurse – Remote

Nurse, Virtual RN

Utilization Management Nurse

Aesthetic Nurse, RN