RN Utilization Specialist/Review Nurse

RN Utilization Specialist/Review Nurse Brentwood, TN Category: Healthcare Employment Type: fulltime ID: 10001633372 Join YesCare: A Career with Purpose in Correctional Healthcare Correctional healthcare is more than just a job—it’s a calling. At YesCare, you have the unique opportunity to make a meaningful difference in the health, well-being, and future of an underserved population. As a pioneer in correctional healthcare services, YesCare is committed to innovation, clinical expertise, and compassionate care. By choosing a career with YesCare, you are opting for professional growth, impactful work, and the chance to be part of a legacy of excellence. You’ll have access to the resources, training, and support needed to enhance your skills and reach your full career potential. Your role at YesCare allows you to contribute directly to the care and well-being of patients who need it most. Join a team that’s known for its innovative approaches and dedication to improving correctional healthcare. Make a difference where it matters most. Start your journey with YesCare today and be part of a team that is transforming lives through care and expertise. Key Responsibilities: The nurse will focus on what’s best for the patients within assigned contracts and involved in the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice and help ensure the best possible health outcome. Assist in the control of utilization of resources, pre-occurrence monitoring, concurrent monitoring, intervention and retrospective review. Track, trend and evaluate appropriateness and quality of care issues with the implementation of education to internal and external customers and process improvement initiatives. Responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice. Facilitate quality health care intervention recommendations. Review and assess over/under utilization issues. Track, trend and evaluate appropriateness and quality of care issues with the implementation of education to internal and external customers and process improvement initiatives. Respond to inquiries by provider/site employees relating to standards of care and best practices. Develop and maintain pre-established review parameters under the direction of the YesCare Medical Director. Identify and document comparisons with community standards, regionally based as indicated. Communicate and guide staff and physicians regarding utilization management program development, implementation, and evaluation and reporting.Match the patient’s needs to the benefit services within the contract specific time frame to ensure resources are maximized. Work with other UM inpatient and outpatient nurse reviewers to assure proper treatment in the appropriate setting at the appropriate time. Participate in CEU offerings/seminars to enhance professional growth and development and the maintenance of nursing license. Recommend improvements to process and outcomes using data analysis tools, logical rules/relations and data elements. Assist in completion of special projects on an as needed basis. Key Qualifications: Registered Nurse (RN) active license No less than 5 years’ experience in utilization management, case management, quality management. Experience with InterQual and/or Milliman Care guidelines and proficient in utilization of those guidelines. Strong organizational and time management skills. Experience and proficiency with ICD-10 coding, CPT and other coding resources Computer usage for word processing, spreadsheets, email, internet, medical records and other proprietary company/client systems. Expert communicator and negotiator with strong verbal, written communication skills. Effectively present information in one-on-one and group situations to nursing staff, clients and other employees of the organization. Extremely detail-oriented and able to handle minute details while overseeing the big picture of coordinated care Resourceful, creative and curious, with a tendency to enjoy problem-solving and finding solutions where others may not see them Ability to work on extremely complex problems where analysis of situations or data requires an evaluation of intangible variance factors. Will work in collaboration with other contract UM Specialists, YesCare’s consulting physicians, RMDs, UMMDs, and Site Physicians to assess, plan, implement, coordinate, monitor and evaluate the options and services required to meet the identified inmate’s needs. YesCare Benefits (For Full-Time Positions) Health, Dental, and Vision Insurance Life and Disability Insurance Generous PTO Plan 401k with Matching Funds Employee Discount and Rewards Program Tuition Assistance Continuing Education Reimbursement Why Join YesCare? YesCare provides a supportive and structured environment where you can thrive in a leadership role while delivering meaningful healthcare in a correctional setting. Your expertise and leadership will directly impact the quality of care and operations within our facilities. Equal Opportunity Employer Statement YesCare is an Equal Opportunity/Affirmative Action Employer . We comply with all federal and state employment opportunity laws and consider qualified applicants without regard to race, gender, national origin, religion, age, sexual orientation, disability, or veteran status.