Utilization Review Nurse- Care Coordination Department

Vassar Brothers Medical Center•Poughkeepsie, NY

58d•$48 - $74•Hybrid

About The Position

The Utilization Review Nurse is responsible for conducting timely, accurate, and comprehensive clinical reviews to ensure that patients receive the appropriate level of care in accordance with regulatory, payer and organizational guidelines. The Utilization Review Nurse applies evidence-based criteria to evaluate medical necessity and collaborates with physicians and interdisciplinary team members to reduce denials and ensure compliance with CMS and payer regulations.

Requirements

Associate's degree in nursing
3 years experience in acute care or subacute care Nursing
Current NYS RN License.

Nice To Haves

3 years experience as Utilization Management Nurse in an acute care or subacute care setting
Bachelor's degree or master's degree in nursing
CCM/ACM Preferred
NYS PRI certification preferred; required within 60 days of hire.
MCG Certification Preferred

Responsibilities

Performs initial, concurrent, and discharge utilization reviews to determine the appropriate patient status (inpatient, observation, outpatient).
Applies InterQual, MCG, or payer-specific criteria in accordance with CMS regulations and the Two-Midnight Rule.
Collaborates with admitting providers to obtain timely admission orders and correct patient status when discrepancies arise.
Ensures MOON, IMN, HINN (etc.) notices are issued and documented per policy.
Conducts timely payer notifications with complete reviews and all supporting clinical documentation via fax or payer portal.
Provides clinical updates and facilitates peer-to-peer reviews as required.
Maintains documentation of all payer interactions in Cerner.
Securely maintains all relevant login credentials for all payer portals.
Demonstrates proficiency in navigating payer portals to efficiently retrieve and submit required data.
Discusses cases with the attending MD when a clinical review does not meet inpatient medical necessity at the first-level review to obtain additional clinical information and documentation to support inpatient level of care; if the case still does not meet criteria, sends it to the Physician Advisor for a second-level review.
Forwards cases requiring secondary physician review to the appropriate resource (e.g., Physician Advisor).
Resolves discrepancies at the time of review or escalates unresolved issues to the Physician Advisor and departmental leadership.
Coordinates with the care team to change patient status as needed.
Notifies the care team when a patient does not meet medical necessity per InterQual, MCG guidelines, or the Two-Midnight Rule and escalates appropriately.
Adheres to all federal, state, payer, and hospital compliance requirements related to utilization management.
Maintains confidentiality of patient information in accordance with HIPAA.
Meets productivity standards, including review volume, timeliness, and documentation quality.
Adheres to the standards outlined in the Nuvance Health Remote Work Program Policy when utilizing a hybrid work arrangement.
Maintains and models organization values.
Demonstrates regular, reliable and predictable attendance.
Performs other duties as required.