RN - Case Manager

Clinical Utilization Review Nurse II

This role involves prospectively and concurrently evaluating the appropriateness of inpatient and observation services. The evaluation is based on clinical documentation, evidence-based guidelines, and insurance benefits. Required clinical information must be communicated to payers according to contractual and regulatory obligations. The Level II Nurse serves as a clinical resource to physicians and providers. Education related to medical necessity, utilization review, and payer requirements is provided. Comprehensive admission and continued-stay reviews for inpatient and observation cases must be performed using facility-approved criteria and payer rules. Utilization review documentation must be accurate, timely, and audit-ready. It should clearly reflect clinical facts, criteria application, and rationale. Opportunities for alternative levels of care should be identified when criteria are not met. Concerns regarding short-stay risk, disputed status, and medical necessity must be escalated to leadership as needed. The Daily Review Tracker and other lists must be consistently maintained, updated, and reviewed in a timely manner. Data integrity should be validated, and gaps or delays should be identified, initiating corrective action as required. Concise clinical summaries for peer-to-peer discussions and payer communications must be prepared. Denial trends, avoidable days, and utilization issues within the assigned workload must be monitored and reported. Collaboration with revenue cycle on claim issues and appeals is essential. Population-specific utilization patterns should be analyzed and communicated. The promotion of evidence-based protocols, pathways, and order sets supports high-quality and cost-effective care. Participation in audits, quality improvement initiatives, and ongoing competency development is encouraged. Effective communication with physicians and co-workers in a customer service-focused manner is necessary. Comprehensive knowledge of health care financial and payer requirements is essential. Comfort with navigating EMRs and maintaining accurate data entry is required. Understanding of federal law regarding certain notices is expected.

We offer competitive benefits, including:

• Medical, dental & vision insurance
• Free and unlimited continuing education units (CEUs)
• 24/7 dedicated Care Line and clinical liaison support
• Personalized career consultant and "single point of contact" service
• Industry?leading pay rates, loyalty rewards & referral bonuses
• Free tax return assistance for travelers
• 401(k) Retirement Plan
• Health Savings Account (HSA)
• Disability Insurance (Short-Term and Long-Term)
• Life and AD&D Insurance
• Paid Sick Leave (where required by applicable state or local law)
• Supplemental Insurance Plans
• Identity Theft Protection
• Pet Insurance
• Employee Wellness Programs
• Employee Assistance Program (EAP)
• Career Growth and Professional Development Opportunities

Benefits eligibility, accrual rates, and usage limits may vary based on employment status, length of service, and work location. Paid Sick Leave is provided in strict accordance with applicable state and municipal mandates. Cynet Health reserves the right to modify, amend, or terminate any benefit plans at any time in accordance with applicable laws.

Cynet Health is a Joint Commission-accredited, Minority-Owned healthcare staffing agency headquartered in Sterling, Virginia, proudly serving healthcare facilities across the United States since its founding in 2010. As one of the nation's largest and fastest?growing healthcare staffing firms in the nation, we staff thousands of nursing, allied health, locum tenens, pharmacy, therapy, direct?hire, and non?clinical professionals across hospitals, clinics, long?term care facilities, labs and more. We're one of the most decorated staffing agencies in America-ranked a Top Travel Nursing Company by BluePipes, recognized among the fastest?growing and most diverse staffing firms by Inc. 5000, Staffing Industry, WBJ and USPAACC-and remain deeply committed to excellence, inclusion, and community impact.

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