Utilization Review Nurse- Care Coordination Department

Utilization Review Nurse

Position at Vassar Brothers Medical Center

Northwell is the largest not-for-profit health system in the Northeast, serving residents of New York and Connecticut with 28 hospitals, more than 1,000 outpatient facilities, 22,000 nurses and over 20,000 physicians. Northwell cares for more than three million people annually in the New York metro area, including Long Island, the Hudson Valley, Connecticut and beyond, thanks to philanthropic support from our communities. Northwell is New York State's largest private employer with over 104,000 employees including members of Northwell Health Physician Partners who are working to change health care for the better.

Summary:

The Utilization Review Nurse is responsible for conducting timely, accurate, and comprehensive clinical reviews to ensure that patients receive the appropriate level of care in accordance with regulatory, payer and organizational guidelines. The Utilization Review Nurse applies evidence-based criteria to evaluate medical necessity and collaborates with physicians and interdisciplinary team members to reduce denials and ensure compliance with CMS and payer regulations.

Responsibilities:

1. Clinical Review & Level of Care Determination

• Performs initial, concurrent, and discharge utilization reviews to determine the appropriate patient status (inpatient, observation, outpatient).
• Applies InterQual, MCG, or payer-specific criteria in accordance with CMS regulations and the Two-Midnight Rule.
• Collaborates with admitting providers to obtain timely admission orders and correct patient status when discrepancies arise.
• Ensures MOON, IMN, HINN (etc.) notices are issued and documented per policy.

2. Payer Communication & Authorization Management

• Conducts timely payer notifications with complete reviews and all supporting clinical documentation via fax or payer portal.
• Provides clinical updates and facilitates peer-to-peer reviews as required.
• Maintains documentation of all payer interactions in Cerner.
• Securely maintains all relevant login credentials for all payer portals.
• Demonstrates proficiency in navigating payer portals to efficiently retrieve and submit required data.

3. Collaboration with Clinical Team

• Discusses cases with the attending MD when a clinical review does not meet inpatient medical necessity at the first-level review to obtain additional clinical information and documentation to support inpatient level of care; if the case still does not meet criteria, sends it to the Physician Advisor for a second-level review.
• Forwards cases requiring secondary physician review to the appropriate resource (e.g., Physician Advisor).
• Resolves discrepancies at the time of review or escalates unresolved issues to the Physician Advisor and departmental leadership.
• Coordinates with the care team to change patient status as needed.
• Notifies the care team when a patient does not meet medical necessity per InterQual, MCG guidelines, or the Two-Midnight Rule and escalates appropriately.

4. Compliance & Performance Standards

• Adheres to all federal, state, payer, and hospital compliance requirements related to utilization management.
• Maintains confidentiality of patient information in accordance with HIPAA.
• Meets productivity standards, including review volume, timeliness, and documentation quality.

5. Hybrid Work Standards and Accountability

• Adheres to the standards outlined in the Nuvance Health Remote Work Program Policy when utilizing a hybrid work arrangement.

Maintains and models organization values.

Demonstrates regular, reliable and predictable attendance.

Performs other duties as required.

Education Skills Experience:

Associate's degree in nursing

3 years experience in acute care or subacute care Nursing

3 years experience as Utilization Management Nurse in an acute care or subacute care setting preferred.

PREFERRED: Bachelor's degree or master's degree in nursing Current NYS RN License.

CCM/ACM Preferred

NYS PRI certification preferred; required within 60 days of hire. MCG Certification Preferred

Working Conditions

Derived Working Conditions

Essential: * Significant manual skills / motor coord & finger dexterity * Significant occupational risk * Very Heavy effort. May exert up to 50 lbs. force * Significant exposure to dirt, odor, noise, human waste, etc.