Utilization Review Nurse (PRN)

Netsmart; United States; Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Remote-friendly work arrangements

Job summary

Netsmart is seeking a registered nurse to perform utilization management reviews for ED admissions, applying InterQual/MCG criteria and evidence-based guidelines to ensure appropriate resource use.

You will collaborate remotely with ED physicians, document reviews, and transmit authorizations to insurers while analyzing utilization patterns for continuous improvement. ED/ACU and case management experience is preferred.

Qualifications

• Current and unrestricted RN license.
• 3+ years of acute care experience in ER/critical care/medical-surgical.
• 2+ years utilization management in acute admission and concurrent reviews.
• InterQual and/or MCG criteria within the last 2 years.
• Proficiency in medical record review in an EMR.
• Experience with Microsoft Office and basic Excel.
• Ability to thrive in a fast-paced environment and adapt to changing needs.
• Passing scores on pre-employment assessments.

Responsibilities

• Review and evaluate electronic medical records of ED admissions for medical necessity using InterQual/MCG criteria.
• Apply evidence-based guidelines to assess utilization of healthcare resources.
• Discuss with ED physicians regarding documentation and admission status.
• Enter clinical review data into system for transmission to insurers for authorization.
• Analyze utilization patterns and identify inappropriate resource use.

Skills

InterQual/MCG criteria

EMR proficiency

Microsoft Excel

Communication

Education

Active RN license

Tools

InterQual

MCG

EMR software

Job description

Job Description

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

Netsmart does not provide work visa sponsorship for this position.

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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.

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Our Netsmart team is vision driven, cause connected and passionate about opportunity.

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