Utilization Review Nurse

Responsible for utilization review work for emergency admissions and continued stay reviews

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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