Utilization Review Nurse
Netsmart
Utilization Review Nurse
Netsmart
Healthcare IT EHR for behavioral health
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
Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.
Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.
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All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.
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Netsmart provides technology solutions for health service providers, focusing on electronic medical records (EHR) and management software for behavioral health and post-acute care. Its products digitize healthcare operations, offering EHRs, workflow and interoperability services, and ongoing support to help organizations switch to value-based care. The platform connects clinicians, administrators, and patients by integrating data across care settings and enabling coordinated, outcomes-driven services. What sets Netsmart apart is its specialization in behavioral health and post-acute sectors, its emphasis on interoperability and ongoing implementation support, and its partnerships with community organizations to expand service delivery. The company aims to help healthcare providers thrive in a changing landscape by linking people, technology, and care to deliver value-based outcomes.
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