Transforming the future of healthcare isn’t something we take lightly. It takes teams of the best and the brightest, working together to make an impact.
As one of the largest healthcare technology companies in the U.S., we are a catalyst to accelerate the journey toward improved lives and healthier communities.
Here at Change Healthcare, we’re using our influence to drive positive changes across the industry, and we want motivated and passionate people like you to help us continue to bring new and innovative ideas to life.
If you’re ready to embrace your passion and do what you love with a company that’s committed to supporting your future, then you belong at Change Healthcare.
Pursue purpose. Champion innovation. Earn trust. Be agile. Include all.
Empower Your Future. Make a Difference.
The Utilization Review (UR) Nurse provides clinical review against nationally recognized medical necessity criteria for the purpose of evaluating medical necessity or hospitalization (inpatient and outpatient observation patients) regardless of payer type. Conducts concurrent and retrospective chart review for clinical, financial and resource utilization information. Retrospective Review of inpatient admissions and outpatient services for Medicaid eligible patients utilizing EMR. systems for all contracted hospitals.
Essential Duties and Responsibilities
- Works on problems of diverse scope where analysis of data requires evaluation of identifiable factors.
- Demonstrates good judgment in selecting methods and techniques for obtaining solutions.
- Networks with senior internal and external personnel in own area of expert
- Retrospective Review of inpatient admissions and outpatient services for Medicaid eligible patients utilizing EMR
- A current unrestricted RN or LPN license is required with either an associate’s or bachelor’s degree or diploma from an accredited nursing program.
- A Bachelor of Science degree is preferred.
- Must have broad nursing background and high degree of professionalism with sound nursing judgement.
- A broad nursing background including a minimum of 2-5 years of nursing experience is required.
- Utilization review experience and/or Care coordination/discharge planning experience required
- Must have excellent critical thinking skills, strong attention to detail and the ability to problem solve effectively
- Must have the ability to exercise independent nursing judgment and to work within established procedures and guidelines as well as to work in a team environment
- Must be knowledgeable and proficient in performing prospective, concurrent and retrospective medical necessity reviews on a variety of services/care levels
- Must have ability to meet deadlines with a variety of responsibilities
- Must demonstrate excellent verbal, written and customer service skills
- Must be knowledgeable and able to assess appropriate levels of care and transitions across the continuum of care
- Must have knowledge of ICD-10 Codes, CPT Codes, HCPCS codes
- Must have experience using Interqual criteria in Critical, Acute, Sub-Acute, and Rehab setting
- Knowledge of Medicare/Medicaid guidelines
- Must be able to review Medicaid/Managed Care denials and process 1st Level appeals
- Must have experience using EMR systems (EPIC, Meditech, Sovera, Cerner, etc)
- Experience in a Third Party Administrator, Managed care, Medicare and/or Medicare environment is desirable.
- 3 or more years' adult and/or pediatric clinical experience in a hospital setting, including at least one year as a utilization review nurse
- A bachelor's degree and state licensure in the relevant jurisdiction as a registered nurse is preferred.
Join our team today where we are creating a better coordinated, increasingly collaborative, and more efficient healthcare system!
Equal Opportunity/Affirmative Action Statement
Change Healthcare is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, genetic information, national origin, disability, or veteran status. To read more about employment discrimination protections under federal law, read
EEO is the Law
at https://www.eeoc.gov/employers/upload/poster_screen_reader_optimized.pdf and the supplemental information at https://www.dol.gov/ofccp/regs/compliance/posters/pdf/OFCCP_EEO_Supplement_Final_JRF_QA_508c.pdf.If you need a reasonable accommodation to assist with your application for employment, please contact us by sending an email to firstname.lastname@example.org with "Applicant requesting reasonable accommodation" as the subject. Resumes or CVs submitted to this email box will not be accepted.Click here https://www.dol.gov/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf to view our pay transparency nondiscrimination policy.Change Healthcare maintains a drug free workplace and conducts pre-employment drug-testing, where applicable, in accordance with federal, state and local laws.