Utilization Review Nurse (PRN/Day Shift)

Brundage Medical Group LLC; Town of Florida (NY); On-site; USD 60,000 - 90,000; Part time

Job summary

Brundage Medical Group LLC is seeking a Utilization Review Nurse (PRN/Day Shift) in New York to perform admission and continued stay reviews ensuring medical necessity, payer requirements, and regulatory compliance. The UR Nurse collaborates with physicians, case managers, and care teams to optimize reimbursement while maintaining quality patient care.

The candidate should have extensive acute care nursing experience, familiarity with InterQual/MCG criteria, and a valid RN license.

Qualifications

• RN license required with current, unrestricted status.
• Minimum five years of acute care nursing experience in a hospital setting.
• Familiarity with InterQual or MCG criteria for reviews.

Responsibilities

• Perform hospital admission reviews to determine medical necessity and patient status (inpatient, observation, outpatient).
• Conduct continued stay reviews using approved clinical criteria and guidelines.
• Evaluate clinical documentation for accuracy, completeness, and payer/regulatory compliance.
• Apply evidence-based criteria such as InterQual and/or MCG.
• Communicate review findings and recommendations to physicians and case management staff.

Skills

RN license

Acute care experience

InterQual/MCG criteria

Communication skills

PRN scheduling

Team collaboration

Education

Graduate of an accredited school of nursing

BSN preferred

Job description

All Jobs > Utilization Review Nurse (PRN/Day Shift)

Part-time

Description

The Utilization Review (UR) Nurse is responsible for conducting admission and continued stay reviews to ensure appropriate utilization of hospital resources and compliance with medical necessity criteria, payer requirements, regulatory standards, and organizational policies. The UR Nurse works collaboratively with physicians, case managers, revenue cycle staff, and interdisciplinary care teams to facilitate appropriate patient status determinations and optimize reimbursement while supporting quality patient care. This position requires extensive acute care nursing experience and demonstrated expertise in utilization review within a hospital setting. This is a PRN position and is subject to the organization’s PRN scheduling, shift, and holiday requirements described below. 4 or 8 hour shifts during the 7a-7p hours.

Requirements

• Perform hospital admission reviews to determine medical necessity and appropriate patient status (inpatient, observation, outpatient).
• Conduct continued stay reviews using approved clinical criteria and guidelines.
• Evaluate clinical documentation for accuracy, completeness, and compliance with payer and regulatory requirements.
• Apply evidence-based criteria such as InterQual® and/or MCG®.
• Communicate review findings and recommendations to physicians, case management staff, and leadership.
• Collaborate with Physician Advisors regarding complex cases or cases not supported by criteria.
• Assist with denial prevention activities and accurate documentation.
• Performs other duties as assigned.
• Proficient in multiple Electronic Health Records and case management systems
• Strong communication skills. Communicates clearly and concisely, verbally and in writing
• Ability to thrive in a fast-paced environment and adapt to frequent changing business needs
• Ability to work independently, needing minimal supervision.
• Graduate of an accredited school of nursing
• Bachelors of Science in Nursing (BSN): preferred
• Current, unrestricted Registered Nurse (RN) license.
• Minimum five (5) years of acute care nursing experience in a hospital setting
• Minimum two (2) years of recent hospital-based or health plan utilization review experience
• Experience with acute admission reviews and continued stay reviews
• Certified Case Manager (CCM), Accredited Case Manager (ACM), or Certified Managed Care Nurse (CMCN), or Case Management Board Certification (CMGT-BC): preferred.
• PRN (per diem) position requiring a minimum of forty (40) hours per month when hours available.
• At least twenty-four (24) of the required monthly hours must be worked on weekend shifts.
• Shift options of four (4) or eight (8) hours, based on departmental needs and manager approval.
• Additional hours may be scheduled based on departmental needs and employee availability.
• Schedule is posted one calendar month at a time; availability must be submitted thirty (30) days in advance (e.g., by June 30 for the August schedule).
• Required to work two (2) of the six (6) organization-recognized holidays each calendar year: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, and Christmas Day.
• Must maintain flexibility and communicate availability in accordance with department scheduling practices.
• Expected to report to work as scheduled and follow all attendance and call-off policies. Failure to meet minimum monthly hours or holiday requirements may result in review of PRN status or corrective action.
• Conditions typically associated with an office environment. While performing the essential duties and responsibilities, the employee is regularly required to speak or hear. May be frequently required to sit, stand or walk. Moderate to prolonged reading, typing, and computer work. Ability to perform tasks involving physical activity that may include lifting up to 25 pounds. Subject to exposure to all environmental hazards associated with healthcare and office work