Utilization Review Nurse- Care Coordination Department

Responsibilities

• Performs initial, concurrent, and discharge utilization reviews to determine the appropriate patient status (inpatient, observation, outpatient).
• Applies InterQual, MCG, or payer-specific criteria in accordance with CMS regulations and the Two-Midnight Rule.
• Collaborates with admitting providers to obtain timely admission orders and correct patient status when discrepancies arise.
• Sends MOON, IMN, HINN (etc.) notices to patients and documents them according to policy.
• Conducts timely payer notifications with complete reviews and all supporting clinical documentation via fax or payer portal.
• Provides clinical updates and facilitates peer-to-peer reviews as required.
• Maintains documentation of all payer interactions in Cerner.
• Safeguards all relevant login credentials for all payer portals.
• Demonstrates proficiency in navigating payer portals to efficiently retrieve and submit required data.
• Collaborates with the clinical team to discuss cases with the attending MD when a clinical review does not meet inpatient medical necessity at the first-level review.
• Forwards cases requiring secondary physician review to the appropriate resource (e.g., Physician Advisor).
• Resolves discrepancies at the time of review or escalates unresolved issues to the Physician Advisor and departmental leadership.
• Coordinates with the care team to change patient status as needed.
• Notifies the care team when a patient does not meet medical necessity per InterQual, MCG guidelines, or the Two-Midnight Rule and escalates appropriately.
• Adheres to all federal, state, payer, and hospital compliance requirements related to utilization management.
• Maintains confidentiality of patient information in accordance with HIPAA.
• Maintains and models organization values.
• Performs other duties as required.

Requirements

• Associate's degree in nursing
• 3 years experience in acute care or subacute care
• Nursing experience in an acute care or subacute care setting preferred
• PREFERRED: Bachelor's degree or master's degree in nursing
• Current NYS RN License
• Certified Coding Manager (CCM)/Certified Utilization Management Professional (ACM) preferred
• NYS PRI certification preferred; required within 60 days of hire
• MCG Certification preferred

Skills

• Proficiency in InterQual, MCG, or payer-specific criteria
• Experience with Cerner documentation systems
• Ability to navigate payer portals
• Strong communication and collaboration skills
• Knowledge of HIPAA and confidentiality protocols

Benefits

• Hybrid work standards and accountability
• Derived Working Conditions: Significant manual skills / motor coordination & finger dexterity, significant occupational risk, very heavy effort, may exert up to 50 lbs. force, significant exposure to dirt, odor, noise, human waste, etc.

Pay

$48.49 - $73.58 per hour

Schedule

Exempt position