Onsite RN Nurse

About the role

The on-site Hospital Utilization Management (UM) Nurse serves as the key liaison between clinical staff and administrative compliance, focusing on optimizing hospital resources through real-time, face-to-face interactions with physicians, patients, and interdisciplinary teams. The role emphasizes active, on-site engagement to influence patient care, ensure compliance, and support hospital throughput and financial performance.

Responsibilities

• Perform admission and concurrent medical record reviews to verify patient classification and ensure care aligns with medical necessity.
• Collaborate directly with physicians during bedside rounds and departmental huddles, providing immediate input on care progression and appropriate levels of care.
• Engage in physician consultations for complex cases, and act as the primary on-site link for medical necessity determinations.
• Conduct on-site reviews using criteria like InterQual or MCG, and deliver legally required notices to patients.
• Identify and escalate avoidable hospital days to minimize financial loss, ensuring compliance with payer regulations and documenting thoroughly.
• Support continuous improvement initiatives and ensure accurate, timely documentation related to clinical reviews and insurance requirements.

Qualifications & Skills

• Associates or Bachelor’s Degree in Nursing; RN license (single-state or multi-state Compact) with required certifications (BLS).
• Minimum of 3 years of clinical experience with strong knowledge of case management processes.
• Excellent communication, organizational, and relationship-building skills.
• Proficiency in utilizing screening criteria, analyzing clinical data, and effective computer skills.