Utilization Review Nurse
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Job Description
Utilization Review Nurse reviewing emergency admissions and continued stays using InterQual or MCG criteria. Supporting authorization decisions and appropriate healthcare resource utilization at Netsmart.
Responsibilities:
- Review and evaluate electronic medical records for emergency department admissions
- Screen admissions for medical necessity using InterQual or MCG criteria
- Apply evidence-based clinical guidelines to assess appropriate utilization of healthcare resources
- Participate in telephonic discussions with emergency department physicians regarding documentation and admission status
- Enter clinical review information into the system for transmission to insurance companies for authorization
- Review, analyze, and identify utilization patterns, trends, problems, or inappropriate resource utilization
- Work assigned shifts between 9am EST and 9pm EST
- Adjust availability or work different shifts based on client needs and operational demands
Requirements:
- Current and unrestricted RN license
- At least 3 years of clinical experience in an acute care setting in emergency room, critical care and/or medical/surgical nursing
- At least 2 years of 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 with Microsoft Suite, including Office and basic Excel
- Ability to thrive in a fast-paced, dynamic environment and adapt to frequently changing business needs
- Passing score(s) on job-related pre-employment assessment(s)
- All applicants must be legally authorized to work in the United States
- No work visa sponsorship is provided
- Preferred: at least 5 years of clinical experience in an acute care setting
- Preferred: at least 3 years of utilization management experience within the hospital setting
- Preferred: Bachelor’s of Science in Nursing (BSN)
- Preferred: case management certifications such as CCM, ACM, CMCN, or CMGT-BC
Benefits:
- Comfortable with remote work arrangements and virtual collaboration tools
- Full-time schedule includes 4 holidays per year
- Full-time schedule includes every other weekend or 4 weekend shifts per month
- Weekend FT schedule available: 3 twelve-hour shifts, including one weekday shift
- Pre-employment background check and drug screen provided at Netsmart’s sole expense
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