Registered Nurse (RN) - Utilization Management / Review

Registered Nurse (RN) - Utilization Management / Review

Location - Syracuse, NY

Duration - 14 Weeks

Position Type: Contract
Short Description

Seeking an experienced Registered Nurse (RN) with strong knowledge of utilization management, hospital admission criteria, and healthcare payer regulations. Preferred experience includes working with MCG or InterQual screening criteria, CMS regulations, and interfacing with healthcare payers and regulatory agencies.
Job Summary

The Registered Nurse (RN) will support utilization management and review activities to ensure appropriate patient care, regulatory compliance, and effective coordination with healthcare payers and interdisciplinary care teams.

The ideal candidate will possess strong clinical assessment skills, knowledge of hospital admission criteria, and experience working in acute care environments. This role requires strong communication skills, attention to detail, and the ability to work independently within a fast-paced healthcare setting.
Key Responsibilities

• Review patient cases for medical necessity and appropriate level of care determination
• Utilize screening criteria tools such as:
  • MCG
  • InterQual
• Ensure compliance with CMS regulations and hospital admission guidelines
• Coordinate with healthcare payers, regulatory agencies, physicians, and care teams
• Support utilization review and case management activities
• Maintain accurate and timely documentation within the electronic medical record system
• Communicate effectively with interdisciplinary healthcare teams regarding patient status and care plans
• Assist in identifying opportunities for process improvement and regulatory compliance
• Provide high-quality patient-centered support while maintaining confidentiality and accuracy

Required Qualifications

• Current New York State Registered Nurse (RN) registration/license
• Current BLS Certification and ability to maintain certification
• Minimum 1.5 years of recent acute care experience within the past 2 years
• Experience working in hospitals of similar or greater size and acuity
• Strong interpersonal and communication skills
• Legal authorization to work in the United States
• Must successfully pass pre-employment health clearance, drug screening, and background check

Preferred Qualifications

• Experience with:
  • MCG screening criteria
  • InterQual criteria
  • CMS regulations related to hospital admissions
  • Utilization Management or Utilization Review
  • Interfacing with healthcare payers and regulatory agencies
• Experience with EPIC Electronic Medical Records preferred
• Experience in Level 1 Trauma hospitals highly preferred

Required Skills

• Strong clinical assessment and decision-making skills
• Knowledge of utilization management processes and regulatory requirements
• Excellent documentation and organizational skills
• Ability to work independently with minimal supervision
• Strong communication and collaboration skills
• Attention to detail and accuracy in case review processes

For more details reach at View email address on click.appcast.io or Call / Text at View phone number on click.appcast.io - EXT 4807 .