Utilization Review Nurse

Community Memorial Health System

Hamilton, NY

Responsibilities and Duties:

Conduct concurrent, retrospective, and pre-admission reviews to determine medical necessity and level of care.
Evaluate clinical documentation to ensure appropriate utilization of services according to established criteria (e.g., InterQual, MCG).
Collaborate with physicians, case managers, and insurance companies to coordinate care and obtain authorization for services.
Identify and report potential delays in care, underutilization, or overutilization of services.
Participate in denial management by preparing and submitting clinical appeals when necessary.
Maintain accurate and timely documentation of utilization review activities in the electronic medical record (EMR) and UR tracking systems.
Ensure compliance with CMS, state regulations, Joint Commission standards, and payer requirements.
Provide education and guidance to clinical staff regarding documentation requirements and utilization criteria.
Support quality improvement initiatives related to care efficiency, patient outcomes, and cost containment.

J ob Requirements:

Minimum 2-3 years of clinical nursing experience (medical-surgical or case management)
Current, active Registered Nurse (RN) licensure
Prior experience in UR, CM, or health insurance review highly desirable
Strong written and verbal skills, proficient computer skills
Excellent clinical judgement, critical thinking, and communication skills
Strong understanding of medical necessity criteria, managed care principles, and reimbursement methodologies.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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Vacancy posted 1 day ago

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