Staff Nurse-Quality

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

About This Role

The Staff Nurse-Quality position at NYC Health and Hospitals involves managing the clinical review of services for patients entitled to Medicare and Medicaid benefits. This role is ideal for nurses who excel in utilization management and are committed to optimizing patient care.

Highlights

• Pay: $112,775/year
• Location: New York, NY
• Facility: NYC Health + Hospitals/Carter
• Department/Unit: NON PSRO UTILIZATION REVIEW
• Schedule: Full-Time, Day shift

What You'll Do

• Evaluate patient medical records and clinical data for medical necessity and appropriateness.
• Conduct concurrent and retrospective reviews using InterQual LTACH criteria or NYS DOH Medicaid criteria.
• Communicate with healthcare providers, patients, and insurance payers to manage costs and optimize care.
• Submit clinical reviews to insurers for authorization of continued stay and reimbursement.
• Complete Patient Review Instrument and update PRI data in EPIC for timely discharges.
• Discuss medical status with physicians and ensure timely determinations from insurance companies.
• Monitor potential service denials and manage appeals in compliance with guidelines.
• Collaborate with interdisciplinary teams and case managers for smooth transitions of care.

Requirements

Experience:

• 3-5 years of clinical bedside experience
• 1-3 years in utilization review, case management, or managed care preferred

Licenses & Certifications:

• Valid New York State RN License required

Additional Compensation

• Annual education differential based on degree:
• Bachelors in allied health discipline = $900
• Masters in allied health discipline = $1,200
• Bachelors of Science in Nursing (BSN) = $1,800
• Masters of Science in Nursing (MSN) = $2,000
• Doctorate in Education, Nursing Practice or PhD in Nursing (DNP) = $2,500
• Annual certification differential ranging from $1,878 up to $4,878 for nationally recognized certifications.
• Annual nursing experience differential ranging from $987 up to $8,190 for up to 10 years of experience.

Benefits

• Comprehensive Health Benefits for employees working 20+ hours per week
• Retirement Savings and Pension Plans
• Paid Holidays and Vacation
• Loan Forgiveness Programs for eligible employees
• College tuition discounts and professional development opportunities
• College Savings Program
• Union Benefits for eligible titles
• Multiple employee discount programs
• Commuter Benefits Programs

About NYC Health and Hospitals

NYC Health + Hospitals is a leading healthcare provider committed to delivering exceptional patient care. The organization operates multiple facilities, including NYC Health + Hospitals/Carter, which is recognized for its quality medical and rehabilitative services.