Utilization Review Nurse

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.