Utilization Review Nurse

External Community Memorial Hospital • Hamilton, NY

3d

About The Position

The Utilization Review Nurse is responsible for conducting various types of reviews to determine the medical necessity and appropriate level of care for services. This role involves evaluating clinical documentation, collaborating with healthcare professionals and insurance companies, and ensuring compliance with regulatory standards. The nurse will also play a key role in denial management, documentation, and providing education to clinical staff to support quality improvement initiatives.

Requirements

• Minimum 2-3 years of clinical nursing experience (medical-surgical or case management)
• Current, active Registered Nurse (RN) licensure
• Strong written and verbal skills, proficient computer skills
• Excellent clinical judgement, critical thinking, and communication skills
• Strong understanding of medical necessity criteria, managed care principles, and reimbursement methodologies.

Nice To Haves

• Prior experience in UR, CM, or health insurance review highly desirable

Responsibilities

• Conduct concurrent, retrospective, and pre-admission reviews to determine medical necessity and level of care.
• Evaluate clinical documentation to ensure appropriate utilization of services according to established criteria (e.g., InterQual, MCG).
• Collaborate with physicians, case managers, and insurance companies to coordinate care and obtain authorization for services.
• Identify and report potential delays in care, underutilization, or overutilization of services.
• Participate in denial management by preparing and submitting clinical appeals when necessary.
• Maintain accurate and timely documentation of utilization review activities in the electronic medical record (EMR) and UR tracking systems.
• Ensure compliance with CMS, state regulations, Joint Commission standards, and payer requirements.
• Provide education and guidance to clinical staff regarding documentation requirements and utilization criteria.
• Support quality improvement initiatives related to care efficiency, patient outcomes, and cost containment.

What This Job Offers

• Career Level: Mid Level