Case Management RN: Utilization Review Specialist

Hudson Regional Hospital; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Hudson Regional Hospital is seeking a Case Management Utilization Review professional to conduct reviews using MCG criteria, promote appropriate resource use, and support department initiatives. You will monitor admissions, perform concurrent and retrospective reviews, and coordinate with physicians to ensure proper care alignment throughout hospitalization.

The role requires a Bachelor’s degree in social work or related field and at least 2 years of experience, with strong interpersonal and

Qualifications

• Bachelor’s degree in social work or related field.
• Excellent interpersonal and communication skills.
• 2+ years related experience.

Responsibilities

• Conducts utilization review using MCG criteria.
• Promotes appropriate utilization of resources.
• Participates in and supports Case Management Department initiatives.
• Determines inpatient criteria applicability for admission decisions.
• Escalates level of care concerns to Case Management Director and Physician Advisor.
• Coordinates with the Patient Access team for timely notices of admission for clinical review.
• Reviews admissions for appropriateness per MCG criteria regardless of payer.
• Provides initial clinical review to commercial insurers as indicated.
• Contacts Physician Advisor when review criteria is not met.
• Monitors electronic medical records to determine continued stay appropriateness.
• Completes continued stay review in EMR every third business day.
• Identifies factors delaying discharge and facilitates correction.
• Documents case management notes with e-signatures; ensure clear connections.

Skills

Interpersonal skills

Communication skills

Education

Bachelor's degree in social work related field

Job description

Hudson Regional Hospital is seeking a Case Management Utilization Review professional to conduct reviews using MCG criteria, promote appropriate resource use, and support department initiatives. You will monitor admissions, perform concurrent and retrospective reviews, and coordinate with physicians to ensure proper care alignment throughout hospitalization.

The role requires a Bachelor’s degree in social work or related field and at least 2 years of experience, with strong interpersonal and