Utilization Review Nurse

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate and assess electronic medical records for admissions in the emergency department.

• Assess admissions for medical necessity utilizing InterQual or MCG criteria.

• Implement evidence-based clinical guidelines to gauge the appropriate use of healthcare resources.

• Engage in telephonic discussions with emergency department physicians concerning documentation and admission status.

• Input clinical review data into the system for submission to insurance companies for authorization.

• Analyze and identify patterns, trends, issues, or inappropriate resource utilization.

• Work assigned shifts between 9am EST and 9pm EST.

• Modify availability or work different shifts according to client requirements and operational needs.

⛳️ Requirements

• Active and unrestricted RN license.

• Minimum of 3 years of clinical experience in an acute care environment, particularly in emergency room, critical care, and/or medical/surgical nursing.

• At least 2 years of experience in utilization management focusing on acute admissions and concurrent reviews.

• Intermediate-level familiarity with InterQual and/or MCG criteria within the past two years.

• Proficient in reviewing medical records using an electronic medical record (EMR) system.

• Competence with Microsoft Suite, including Office and basic Excel.

• Ability to excel in a fast-paced, dynamic environment and adapt to rapidly changing business needs.

• Successful completion of job-related pre-employment assessments.

• All applicants must have legal authorization to work in the United States.

• No work visa sponsorship will be provided.

• Preferred: a minimum of 5 years of clinical experience in an acute care setting.

• Preferred: at least 3 years of experience in utilization management within a hospital setting.

• Preferred: Bachelor’s of Science in Nursing (BSN).

• Preferred: case management certifications such as CCM, ACM, CMCN, or CMGT-BC.

🏝️ Benefits

• Comfortable remote work arrangements and use of virtual collaboration tools.

• Full-time schedule includes 4 holidays per year.

• Full-time schedule requires working every other weekend or 4 weekend shifts per month.

• Weekend full-time schedule available: 3 twelve-hour shifts, including one weekday shift.

• Pre-employment background check and drug screening are conducted at Netsmart’s expense.