Utilization Reviewer (RN) - Emergency Department, Full Time, Days, 8 AM - 4 PM, Atlantic Health Overlook Medical Center

Utilization Reviewer (RN) Emergency Department

Atlantic Health System is seeking a Full-Time Utilization Reviewer RN to support Emergency Department operations at Overlook Medical Center. The Utilization Reviewer is responsible for conducting real-time medical necessity reviews and level-of-care determinations for patients presenting to the Emergency Department. This role serves as a key liaison between clinical teams and utilization management to ensure appropriate patient status assignment, regulatory compliance, and optimal patient throughput.

Responsibilities:

• Perform concurrent medical necessity reviews for Emergency Department patients utilizing MCG and/or InterQual criteria.
• Evaluate admission, observation, and level-of-care determinations in accordance with CMS, payer, and organizational guidelines.
• Collaborate with Emergency Department physicians, hospitalists, physician advisors, and care management teams to support timely patient placement decisions.
• Provide education and guidance regarding CMS Observation Rules, Two-Midnight Rule, and documentation requirements.
• Identify potential denial risks and compliance concerns and escalate as appropriate.
• Communicate patient status determinations and pertinent clinical information to inpatient Utilization Review staff for continuity of care.
• Participate in departmental quality initiatives, data collection, reporting, and performance improvement activities related to utilization management and patient throughput.
• Maintain current knowledge of regulatory and payer requirements impacting utilization review practices.

Qualifications

Required:

• Graduate of an accredited School of Nursing.
• Current New Jersey Registered Nurse (RN) License in good standing.
• Strong clinical assessment and critical thinking skills.
• Excellent communication and interdisciplinary collaboration abilities.

Preferred:

• Bachelor of Science in Nursing (BSN).
• Previous Case Management, Utilization Review, or Care Coordination experience.
• Experience utilizing MCG and/or InterQual criteria.
• Knowledge of CMS regulations, Observation Status requirements, and Utilization Management principles.
• Prior Emergency Department, Acute Care, Case Management, or Clinical Documentation experience.