Registered Nurse – Utilization Review - RNSC

NavitasPartners•Syracuse, NY

2d•Onsite

About The Position

We are seeking an experienced Registered Nurse (RN) with Utilization Review and acute care experience to support medical necessity reviews, regulatory compliance, and care coordination activities. The RN will collaborate with physicians, case managers, insurance providers, and interdisciplinary teams to ensure appropriate utilization of healthcare services while promoting quality and cost-effective patient care.

Requirements

Active New York State Registered Nurse (RN) License required.
Current BLS Certification required or ability to recertify.
Minimum 1.5 years of recent acute care hospital experience required.
Knowledge of CMS regulations related to hospital admissions and inpatient criteria required.
Clean professional license history with no suspensions, investigations, or malpractice claims.
Must pass all required health, drug screening, and background check requirements.

Nice To Haves

Utilization Review, Utilization Management, or Case Management experience strongly preferred.
Familiarity with InterQual and/or MCG criteria required or strongly preferred.
Experience working with healthcare payers and regulatory agencies preferred.
EPIC EMR experience preferred.

Responsibilities

Conduct clinical reviews for inpatient admissions and continued stay authorization.
Apply InterQual, MCG, and evidence-based criteria for medical necessity determinations.
Review patient charts and clinical documentation for appropriateness of care.
Collaborate with physicians, case managers, and interdisciplinary teams.
Communicate with insurance companies, payers, and regulatory agencies regarding authorization decisions.
Support discharge planning and appropriate level-of-care transitions.
Ensure compliance with CMS regulations and hospital policies.
Document utilization review decisions accurately and timely in EMR systems.