RN Utilization Review Specialist for Care Optimization

Community Memorial Hospital, Inc.; Village of Hamilton (NY); Sur place; USD 85 000 - 95 000; Plein temps

Résumé du poste

Community Memorial Hospital, Inc. in Hamilton, NY is seeking a Registered Nurse to conduct utilization reviews, determine medical necessity, and coordinate authorizations with physicians and insurers. The role requires 2–3 years of clinical nursing experience and active RN licensure.

You will evaluate documentation, report utilization issues, and support quality improvement while ensuring CMS and payer compliance, with a focus on efficient, high-quality patient care.

Qualifications

• Minimum 2–3 years of clinical nursing experience (medical-surgical or case management).
• Current, active RN licensure.
• Prior experience in UR, CM, or health insurance review highly desirable.
• Strong written and verbal communication, proficient computer skills.
• Strong understanding of medical necessity criteria, managed care principles, and reimbursement methodologies.

Responsabilités

• 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 criteria (InterQual, MCG).
• Collaborate with physicians, case managers, and insurers to coordinate care and obtain authorization.
• Identify and report delays, underutilization, or overutilization of services.
• Participate in denial management by preparing and submitting clinical appeals when necessary.
• Maintain accurate documentation in the EMR and UR tracking systems.
• Ensure compliance with CMS, state regulations, Joint Commission standards, and payer requirements.
• Provide education to clinical staff regarding documentation and utilization criteria.
• Support quality improvement initiatives related to care efficiency, patient outcomes, and cost containment.

Connaissances

Clinical nursing

UR review

Case management

Healthcare reimbursement

Written and verbal communication

Formation

RN licensure

Description du poste

Community Memorial Hospital, Inc. in Hamilton, NY is seeking a Registered Nurse to conduct utilization reviews, determine medical necessity, and coordinate authorizations with physicians and insurers. The role requires 2–3 years of clinical nursing experience and active RN licensure.

You will evaluate documentation, report utilization issues, and support quality improvement while ensuring CMS and payer compliance, with a focus on efficient, high-quality patient care.