Staff Nurse-Quality

NYC Health + Hospitals; New York (NY); On-site; USD 85,000 - 115,000; Full time

Job summary

NYC Health + Hospitals Carter seeks a Registered Nurse to perform Utilization Management within LTACH settings. You will review records, determine medical necessity, and coordinate care with providers and payers.

Role requires NY RN license and BLS, with 3–5 years bedside experience and 1–3 years in utilization review. Strong communication and EPIC proficiency are essential for successful patient transitions and approvals.

Qualifications

• Valid New York State RN license and registration.
• Current Basic Life Support (BLS) certification.
• 3–5 years in clinical bedside roles; 1–3 years in utilization review/case management preferred.

Responsibilities

• Evaluate medical records to determine medical necessity and appropriate level of care.
• Communicate with providers, patients, and payers to secure authorizations and manage continued stays.
• Document care plans and summaries in the EPIC system for accurate discharge planning.
• Collaborate with interdisciplinary teams to optimize transitions of care and reduce avoidable hospital days.

Skills

Nursing

Utilization review

Care coordination

EPIC

Communication

Education

NY RN license

BLS certification

Tools

EPIC

Job description

Marketing Statement

NYC Health + Hospitals/Carter is a state-of-the-art facility with a 4-Star CMS Quality Rating, equipped with 164-bed Skilled Nursing Facility and 201-bed Long-Term Acute Care Hospital (LTACH) based in Harlem. Carter excels at providing quality medical, sub-acute, rehabilitative, and long‑term specialty services for individuals in need of medically‑complex care like ventilator weaning and onsite‑dialysis. Every employee takes a person‑centered approach that exemplifies our ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnership.

Marketing Statement

NYC Health + Hospitals/Carter is a state-of-the-art facility with a 4-Star CMS Quality Rating, equipped with 164-bed Skilled Nursing Facility and 201-bed Long-Term Acute Care Hospital (LTACH) based in Harlem. Carter excels at providing quality medical, sub-acute, rehabilitative, and long‑term specialty services for individuals in need of medically‑complex care like ventilator weaning and onsite‑dialysis. Every employee takes a person‑centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnership.

From more than 600 Nursing Homes in New York, Carter ranks #4 in Newsweek’s Best Nursing Homes in New York2026; and also received a high‑performance rating for Long‑Term Care and Short‑term Rehabilitation from U.S. News & World Report’s Best Nursing Homes in America 2026. In 2025, Carter was awarded the American Nurses Credentialing Center’s Pathway to Excellence with Distinction Award, the nation’s first long‑term facility to receive it.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person‑centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Duties & Responsibilities

In accordance with Code of Federal Regulations (CFR), Title 42- Public Health, Section 482.30 (Conditions of Participation for Utilization Review), the Utilization Management provides clinical review of services furnished by the institution/by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs.

POSITION OVERVIEW

UM Staff Nurse act as a bridge between healthcare providers, patients, and insurance payers to manage costs and optimize care of LTACH patients, daily conduct concurrent, and retrospective (post‑treatment) reviews using InterQual LTACH criteria or NYS DOH Medicaid criteria. UM Nurse evaluates patient medical records and clinical data to ensure that healthcare services are medically necessary, appropriate, and delivered in the most efficient setting. Daily conduct and writes a short clinical summary in EPIC documenting the appropriate level of patient’s care. Collaborate with interdisciplinary teams and case managers to support smooth transitions of care and reduce avoidable hospital days.

ESSENTIAL FUNCTIONS

• UM Staff Nurse evaluates patient medical records and clinical data to ensure that healthcare services are medically necessary, appropriate, and delivered in the most efficient setting. Daily conduct and writes a short clinical summary in EPIC documenting the appropriate level of patient’s care. 2-3 hours
• Daily contact healthcare providers, patients, and insurance payers to manage costs and optimize care of LTACH patients, daily conduct concurrent, and retrospective (post‑treatment) reviews using InterQual LTACH criteria or NYS DOH Medicaid criteria. 1-2 hours
• Daily Communicates with third party payors/insurers using insurance specific guidelines, conditions and time‑frames by submitting all clinical reviews to the insurers for obtaining authorization for continued stay in LTACH and proper reimbursement. Communicates all anticipated denials to the Associate Executive Director and to the interdisciplinary care team, if necessary, initiates timely referrals to Physician Advisor. -2-3 hours
• Daily completes Patient Review Instrument and updates PRI data into EPIC for ALOC patients to process with timely discharges, provides information to insurers, providers, and internal staff regarding covered and non‑covered benefits- 1-2 hours
• Daily interconnects with physicians involved in a patient’s care to discuss medical status of the patents. Ensures timeliness in obtaining determinations from the insurance company and follows up on pending determinations. Maintains confidentiality of patient and hospital records and uses discretion when discussing patient and hospital matters. 30min -1 hour
• Monitor potential service denials, manage appeals, and ensure adherence to state, federal, and Medicare Advantage guidelines When needed, complete and submit all necessary clinical information pertaining to all discharge appeals with the QIO’s such as Livanta and IPRO 2‑3 hours 1-2 hours
• Clinical Reviews: Conduct prospective (pre‑treatment), concurrent (during a stay), and retrospective (post‑treatment) reviews using InterQual LTACH criteria or NYS DOH Medicaid criteria
• Insurance Authorizations: Evaluate and process requests for medical procedures, hospital admissions, continued stay, ALOC placement and obtaining the appropriate ALOC authorization with a proper ALC reimbursement
• Discharge Planning: Collaborate with interdisciplinary teams and case managers to support smooth transitions of care and reduce avoidable hospital days.
• Compliance & Denials: Monitor potential service denials, manage appeals, and ensure adherence to state, federal, Medicare Advantage guidelines and managed care regulations

Minimum Qualifications

• A valid New York State license and current registration to practice as a Registered Professional Nurse in New York State; and
• Holds, or obtains through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).

Special Note

For assignments in Post‑Acute Care ONLY, individuals meeting the following criteria may also be considered for appointment: Graduation from a nursing education program registered by the New York State Education Department (NYSED) as licensure qualifying for Registered Professional Nurse (RN) and has applied for licensure as an RN. These unlicensed individuals may be employed to practice under the immediate and personal supervision of a NYS licensed, currently registered, RN for up to 90 days immediately following graduation pending receipt of a limited permit, which selected candidates must apply for and receive within the same 90‑day period. Once a limited permit is received, individuals can practice nursing, under the immediate and personal supervision of a NYS licensed, currently registered, RN at a NYC Health + Hospitals health care setting for up to one (1) year from the date of issuance of the limited permit. In addition, must hold or obtain through facility orientation, a valid and current certification in Basic Life Support (BLS) through the American Heart Association (AHA).

Department Preferences

• Education: Bachelor degree in nursing required or Bachelor of Science in Nursing (BSN) preferred.
• Experience: 3-5 years of clinical bedside, experience 1 to 3 years in utilization review, case management, or managed care is a plus
• Skills: Working knowledge with electronic health records (e.g., Epic) and solid understanding of third‑party payer regulations (Medicare/Medicaid), Being certified in completion of PRI s is preferable, strong communication skills