About This Role
This nursing role focuses on utilization review for emergency admissions and ongoing patient stays. The nurse will evaluate medical records, apply clinical guidelines, and communicate with physicians to ensure appropriate healthcare resource utilization.
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 the system for transmission to insurance companies for authorization
- Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources
Requirements
- 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)
Nice to have:
- 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)
Important Details
- Schedule: 8-hour, 10-hour or 12-hour shifts, working between 9am EST and 9pm EST
- Full-time required to work 4 holidays per year
- Full-time required to work every other weekend or 4 weekend shifts per month
- Additional shifts available: Weekend full-time (3, 12-hour shifts, one shift worked during a weekday)
- Work schedules and shift assignments are subject to change based on evolving client needs and operational demands; flexibility and adaptability are essential
Other Conditions
