Utilization Review Nurse

Community Memorial Hospital, Inc.; Village of Hamilton (NY); On-site; USD 85,000 - 95,000; Full time

Job summary

Community Memorial Hospital, Inc. in Hamilton, NY is seeking a Registered Nurse to conduct utilization reviews, determine medical necessity, and coordinate authorizations with physicians and insurers. The role requires 2–3 years of clinical nursing experience and active RN licensure.

You will evaluate documentation, report utilization issues, and support quality improvement while ensuring CMS and payer compliance, with a focus on efficient, high-quality patient care.

Qualifications

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

Responsibilities

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

Skills

Clinical nursing

UR review

Case management

Healthcare reimbursement

Written and verbal communication

Education

RN licensure

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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