RN Utilization Review Specialist for Care & Compliance

Community Memorial Hospital, Inc.; New York (NY); Sur place; USD 85 000 - 95 000; Plein temps

Résumé du poste

Community Memorial Hospital, Inc. is seeking an experienced RN to lead utilization review activities at our Hamilton, NY facility. You will conduct concurrent, retrospective, and pre-admission reviews to determine medical necessity and level of care.

Work with physicians, case managers, and payers to obtain authorizations, report delays, and support cost containment while ensuring CMS and Joint Commission compliance.

Qualifications

• Minimum 2–3 years of clinical nursing experience (medical-surgical or case management).
• Active RN licensure is required.
• Prior UR, CM, or health insurance review experience is desirable.

Responsabilités

• Conduct concurrent, retrospective, and pre-admission reviews to determine medical necessity and level of care.
• Evaluate clinical documentation for appropriate utilization according to criteria (e.g., InterQual, MCG).
• Collaborate with physicians, case managers, and insurers to coordinate care and obtain service authorization.
• Identify and report delays, underutilization, or overutilization of services.
• Participate in denial management by preparing and submitting clinical appeals when needed.
• Maintain accurate EMR UR documentation and tracking.

Connaissances

Clinical nursing

UR review

Communication skills

Computer literacy

Formation

RN licensure

Outils

EMR systems

UR tracking systems

Description du poste

Community Memorial Hospital, Inc. is seeking an experienced RN to lead utilization review activities at our Hamilton, NY facility. You will conduct concurrent, retrospective, and pre-admission reviews to determine medical necessity and level of care.

Work with physicians, case managers, and payers to obtain authorizations, report delays, and support cost containment while ensuring CMS and Joint Commission compliance.