Utilization Review Nurse (PRN/Evening Shift)

Brundage Group; Town of Florida (NY); On-site; USD 45,000 - 65,000; Full time

Job summary

Brundage Group seeks an experienced Utilization Review Nurse for PRN evening shifts at a New York hospital. You will perform admission reviews, assess patient status, and collaborate with physicians and care teams to optimise reimbursement and care quality.

The role requires RN licensure, 5+ years in acute care and utilization review, and familiarity with InterQual/MCG criteria. PRN hours and weekend requirements apply, with shift options of 4 or 8 hours.

Qualifications

• Graduate of an accredited nursing program with active RN license.
• BSN preferred for continued education and leadership opportunities.
• Certifications in case management are preferred (CCM/ACM/CMCN or CMGT-BC).

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 (InterQual/MCG).
• Evaluate clinical documentation for accuracy, completeness, and compliance with payer and regulatory requirements.
• Collaborate with physicians, case management, and leadership to communicate findings and recommendations.

Skills

Strong communication

Independent work

Adaptability

Fast-paced environment

Education

RN license

BSN preferred

CCM/ACM/CMCN/CMGT-BC

Tools

Electronic Health Records

Case Management Systems

Job description

Description

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

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-recognised 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.