Quality Staff Nurse: Utilization Review & Care Optimization

IntelliResume; New York (NY); On-site; USD 101,000 - 124,000; Full time

Benefits offered by this job

Health benefits

Paid time off and holidays

Loan forgiveness programs

College tuition discounts

Commuter benefits

Job summary

NYC Health + Hospitals is seeking a Staff Nurse-Quality in New York, NY to lead clinical review of services for Medicare/Medicaid patients. The role focuses on utilization management and optimization of patient care.

The position requires 3–5 years bedside nursing and 1–3 years in utilization review, with NY RN license and EPIC familiarity. The role offers a day shift, full-time schedule and a comprehensive benefits package.

Qualifications

• 3–5 years of bedside nursing experience.
• 1–3 years in utilization review, case management or managed care preferred.
• Valid New York State RN license is required.
• Experience with EPIC and utilization review criteria is a plus.

Responsibilities

• Evaluate patient records for medical necessity and appropriateness.
• Perform concurrent and retrospective reviews using established criteria.
• Communicate with providers, patients and payers to manage costs and care.
• Submit reviews to insurers for authorization of continued stay.
• Update PRI data in EPIC and ensure timely discharges.
• Discuss status with physicians and secure timely determinations.
• Monitor denials and manage appeals per guidelines.
• Collaborate with care team for smooth transitions.

Skills

Clinical bedside experience

Utilization review experience

Communication with providers

Education

Registered Nurse (RN) NY State license

Tools

EPIC EHR

InterQual LTACH criteria

NYS Medicaid criteria

Job description

NYC Health + Hospitals is seeking a Staff Nurse-Quality in New York, NY to lead clinical review of services for Medicare/Medicaid patients. The role focuses on utilization management and optimization of patient care.

The position requires 3–5 years bedside nursing and 1–3 years in utilization review, with NY RN license and EPIC familiarity. The role offers a day shift, full-time schedule and a comprehensive benefits package.