Utilization Review Nurse

Job Description:

• 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