Utilization Review Nurse

Netsmart; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Netsmart is seeking a registered nurse to perform utilization review for emergency department admissions and ongoing stay reviews. You will evaluate EMRs, apply InterQual/MCG criteria, and collaborate with ED physicians to determine admission status.

This remote-friendly role requires 3+ years acute care and 2+ years utilization management, with BSN preferred. You will document reviews for insurer authorization and monitor utilization patterns across shifts.

Qualifications

• Current and unrestricted RN license.
• At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
• At least 2 years utilization management experience in acute admission and concurrent reviews
• Intermediate level experience with InterQual and/or MCG criteria within the last two years
• Proficiency in medical record review in an electronic medical record (EMR)
• Experience in Microsoft Suite including Office and basic Excel
• Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs
• Passing score(s) on job-related pre-employment assessment(s)

Responsibilities

• Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria
• Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources
• Participate in telephonic discussions with emergency department physicians relative to documentation and admission status
• Enter clinical review information into system for transmission to insurance companies for authorization
• Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources

Education

Bachelor's of Science in Nursing (BSN)

Tools

InterQual

MCG criteria

Job description

Responsible for utilization review work for emergency admissions and continued stay reviews.

Responsibilities

• Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria
• Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources
• Participate in telephonic discussions with emergency department physicians relative to documentation and admission status
• Enter clinical review information into system for transmission to insurance companies for authorization
• Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources

Qualifications Required

• Current and unrestricted RN license
• At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
• At least 2 years utilization management experience in acute admission and concurrent reviews
• Intermediate level experience with InterQual and/or MCG criteria within the last two years
• Proficiency in medical record review in an electronic medical record (EMR)
• Experience in Microsoft Suite including Office and basic Excel
• Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs
• Passing score(s) on job-related pre-employment assessment(s)

Preferred

• At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
• At least 3 years utilization management experience within the hospital setting
• Bachelor's of Science in Nursing (BSN)
• Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC)

Expectations: Comfortable with remote work arrangements and virtual collaboration tools.

Physical demands include extended periods of sitting, computer use, and telephone communication.

Shifts

• Requirements & Needs: Working between the hours of 9am EST and 9pm EST either for 8-hour, 10-hour or 12-hours shifts.
• All Full-Time required to work 4 Holidays per year.
• All Full-time required to work every other weekend or 4 weekend shifts per month.
• Additional Shifts Available: Weekend FT Available - (3, 12 hours shifts, one shift worked during a weekday)

Work schedules and shift assignments are subject to change based on evolving client needs and operational demands. While we strive to provide consistent scheduling, associates may be required to adjust their availability or work different shifts. Flexibility and adaptability are essential for success in this role.

Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals.

We celebrate diversity and are committed to creating an inclusive environment for all associates.

All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience.

Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law.

Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense.

In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

If you are located in a state which grants you the right to receive information on salary range, pay scale, description of benefits or other compensation for this position, please use this form to request details which you may be legally entitled.

All applicants for employment must be legally authorized to work in the United States.

Netsmart does not provide work visa sponsorship for this position.

Netsmart's Job Applicant Privacy Notice may be found here.

Have you ever been to a doctor’s office and submitted your information electronically? Had a telehealth video visit with a therapist? Or scheduled a follow-up visit with your provider through a mobile app? These are just a few examples of how you may have used healthcare technology software in your life as a consumer. Many people view the operating system of healthcare as the electronic health record, but at Netsmart we have a comprehensive platform of solutions and services we offer for our clients. At Netsmart, we provide our post-acute and human services clients with advanced technology to better serve the individuals and patients in their care. Our Netsmart team is vision driven, cause connected and passionate about opportunity. A combination of inspiration through our client work paired with the ability to innovate and explore fuels the success of our associates and company as a whole. Netsmart is focused on providing a candidate experience that mirrors our associate experience. The CandE Winners - Talent Board We are proud to be named one of Ingram’s Best Companies to Work For. If you require accessibility assistance or accommodation for a disability when navigating our website or completing the application process, please contact 1-800-842-1973, option 4 or [e-mail] for assistance. US Applicants: Learn more about your EEO rights under the law (en Español). Netsmart’s Aff…