Utilization Review Nurse (PRN)

Netsmart Technologies, Inc.; United States; Remote; USD 75,000 - 110,000; Full time

Benefits offered by this job

Remote-friendly work arrangements

Job summary

Netsmart Technologies, Inc. is seeking a Registered Nurse with utilization management experience to review ED admissions and apply InterQual/MCG criteria for medical necessity. You will discuss documentation with ED physicians and ensure proper authorization through EMR-based workflows.

Ideal candidates have 3+ years in acute care nursing and 2+ years in utilization management, with proficiency in EMR and MS Office. Remote work arrangements are supported where appropriate.

Qualifications

• Current and unrestricted RN license.
• At least 3 years clinical experience in acute care settings (ER/ICU/med-surg).
• At least 2 years utilization management experience in acute admission and concurrent reviews.
• InterQual and/or MCG criteria experience within the last two years.
• Proficiency in medical record review in an EMR.
• Experience with Microsoft Office including basic Excel.
• Ability to thrive in a fast-paced, dynamic environment and adapt to changing business needs.
• Passing score(s) on pre-employment assessments.

Responsibilities

• Review and evaluate electronic medical records of ED 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 ED physicians regarding documentation and admission status.
• Enter clinical review information into the system for transmission to insurance companies for authorization.
• Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources.

Tools

EMR systems

Microsoft Office

Excel

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.

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.