Utilization Review Nurse

Merrimack Health; Lawrence (MA); On-site; USD 85,000 - 100,000; Full time

Job summary

Merrimack Health seeks an experienced nurse for case management in an acute care setting. The role focuses on admission appropriateness, resource utilization, and determining medical necessity for continued stay.

You will collaborate with the Clinical Care Coordinator and Complex Care Manager to ensure timely discharge and accurate documentation of severity of illness, aligned with payer regulations.

Qualifications

• Graduate of an accredited professional nursing school.
• Current Massachusetts Nursing license.
• 5 years case management experience in an acute care setting with discharge planning, continuing care, care management, and utilization review.

Responsibilities

• Determines appropriateness of hospital admission and utilization of resources.
• Assesses medical necessity for continued stay and ensures compliance with payer regulations.
• Collaborates with Clinical Care Coordinator and Complex Care Manager to facilitate timely discharge and accurate documentation of severity of illness.

Skills

Case management

Discharge planning

Utilization review

Care coordination

Education

Graduate of accredited nursing program

Massachusetts Nursing license

Job description

Responsible for determining the appropriateness of hospital admission, utilization of resources and medical necessity for continued stay. Responsible for working with the Clinical Care Coordinator and Complex Care Manager to facilitate timely discharge, assure medical documentation accurately reflects the patient’s severity of illness; and ensures compliance with the conditions of participation as they relate to utilization review and discharge planning and payer regulations.

MINIMUM EDUCATION AND EXPERIENCE:

Required:

• Graduate of an accredited professional nursing school
• Current Massachusetts Nursing license
• 5 years case management experience in an acute care setting with discharge planning, continuing care, care management, and utilization review.