Utilization Review Nurse - Full-Time
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)
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
Shifts Requirements & Needs:
- Working between the hours of 9am EST and 9pm EST either for 8-hour, 10-hour or 12-hours shifts.
- All Full-Time required to work 4 Holidays per year
- All Full-time required to work every other weekend or 4 weekend shifts per month.
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