Utilization Review Nurse, Full-Time (9a-9p EST), Remote

NetSmart Technologies; United States; Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a skilled RN for utilization review work focused on emergency admissions. This role involves reviewing electronic medical records and applying clinical guidelines to ensure proper utilization of healthcare resources. The ideal candidate will have significant clinical experience, particularly in acute care settings, and be proficient in utilizing InterQual and MCG criteria. Join a dynamic team that values adaptability and offers a supportive remote work environment. If you're passionate about optimizing healthcare delivery and ensuring quality patient care, this opportunity is perfect for you.

Qualifications

• Current RN license required with 3+ years in acute care.
• Experience with InterQual/MCG criteria and EMR review.

Responsibilities

• Review electronic medical records for emergency admissions.
• Participate in discussions with emergency department physicians.

Skills

Utilization Management

Clinical Assessment

Emergency Room Experience

InterQual Criteria

MCG Criteria

Electronic Medical Records (EMR)

Microsoft Office Suite

Adaptability

Education

Current RN License

Bachelor's of Science in Nursing (BSN)

Tools

Microsoft Excel

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

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.

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