Why MediGold

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. Were 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 Management MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers the members family and other resources as appropriate. Assist in the development of the Plans UM Program and the review of the Plans Utilization Management Plan.

What you will do

• Participates in designated committees and task forces according to the UM Program and at the direction of the Director Utilization 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 Bachelors Degree in Nursing
• Licensure / Certification: RN with current unrestricted state licensure required nursing compact license is preferred. Ability to obtain licenses from other participating states
• Experience: Minimum of 5-7 years of clinical nursing experience. 2 years experience in prior authorization utilization review hospital appeals or case management preferred.
• Effective Communication Skills
• Demonstrated ability to analyze summarize and concisely report medical utilization and medical chart audit results.
• Proven ability to work independently with attention to accuracy and consistency of information obtained and recorded.
• PC computer skills required.
• 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

Position Highlights and Benefits:

• Mount Carmel Health System recognized by Forbes in 2025 as one of Americas Best State Employers.
• 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.
• RN to BSN tuition 100% paid at Mount Carmels College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay - if youre hired as an eligible colleague youll be able to see how much youve made every day and transfer your money any time before 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 Ohios largest undergraduate graduate and doctor of nursing programs. If youre 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.