Job Description

Utilization Review Nurse

Responsible for utilization review work for emergency admissions and continued stay reviews.

Responsibilities:

• Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria.
• Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources.
• Participate in telephonic discussions with emergency department physicians relative to documentation and admission status.
• Enter clinical review information into system for transmission to insurance companies for authorization.
• Review, analyze and identify utilization patterns and trends, problems, or inappropriate utilization of resources.

Qualifications: Required

• Current and unrestricted RN license.
• At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing.
• At least 2 years utilization management experience in acute admission and concurrent reviews.
• Intermediate level experience with InterQual and/or MCG criteria within the last two years.
• Proficiency in medical record review in an electronic medical record (EMR).
• Experience in Microsoft Suite including Office and basic Excel.
• Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs.
• Passing score(s) on job-related pre-employment assessment(s).

Qualifications: Preferred

• At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing.
• At least 3 years utilization management experience within the hospital setting.
• Bachelor's of Science in Nursing (BSN).
• Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC).

Expectations:

• Comfortable with remote work arrangements and virtual collaboration tools.
• Physical demands include extended periods of sitting, computer use, and telephone communication.

Shift Needs & Work Requirements:

• Clarify shifts needed with all new openings: Example: Evening Shift - 4p - 12 am ET, working 4-8 pm or 8p-12a. (4 hours shifts).
• Must work 4 holidays per year, each for a 4-hour shift.
• 16 hours of the required 48 hours per month must be worked on the weekend.
• Work schedules and shift assignments are subject to change based on evolving client needs and operational demands. While we strive to provide consistent scheduling, associates may be required to adjust their availability or work different shifts. Flexibility and adaptability are essential for success in this role.

Job Tags

Similar Jobs