Utilization Review Nurse

Community Memorial Hospital, Inc.; New York (NY); On-site; USD 85,000 - 95,000; Full time

Job summary

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.

Responsibilities

• 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.

Skills

Clinical nursing

UR review

Communication skills

Computer literacy

Education

RN licensure

Tools

EMR systems

UR tracking systems

Job description

Community Memorial
Hamilton, NY 13346, USA

• Pay or shift range: $85,000 USD to $95,000 USD
  The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons.

Description

Responsibilities and Duties:

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

Job Requirements:

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

Qualifications

Licenses & Certifications

Required

Registered Nurse

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
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