Utilization Review Nurse, Full-Time (9a-9p EST), Remote
Apply NowLocation:
US
Company:
Netsmart provides healthcare technology solutions to improve the delivery of care and enhance patient outcomes.
Summary:
The Utilization Review Nurse will conduct reviews for emergency admissions and ensure the proper utilization of healthcare resources. Applicants should hold an RN license and have a minimum of 3 years clinical experience in acute care settings, along with utilization management experience.
Requirements:
Credentials: RN license
Experience: 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing, 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
Job Description:
Responsible for utilization review work for emergency admissions and continued stay reviews
Responsibilities
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Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria
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Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources
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Participate in telephonic discussions with emergency department physicians relative to documentation and admission status
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Enter clinical review information into system for transmission to insurance companies for authorization
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Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources
Qualifications
Required
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Current and unrestricted RN license
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At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
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At least 2 years utilization management experience in acute admission and concurrent reviews
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Intermediate level experience with InterQual and/or MCG criteria within the last two years
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Proficiency in medical record review in an electronic medical record (EMR)
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Experience in Microsoft Suite including Office and basic Excel
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Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs
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Passing score(s) on job-related pre-employment assessment(s)
Preferred
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At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
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At least 3 years utilization management experience within the hospital setting
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Bachelor's of Science in Nursing (BSN)
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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
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Comfortable with remote work arrangements and virtual collaboration tools
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Physical demands include extended periods of sitting, computer use, and telephone communication
