Utilization Review Nurse

Community Memorial Hamilton, NY 13346, USA Pay or shift range: $85,000 USD to $95,000 USD The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons. Description 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. Job 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. Qualifications Licenses & Certifications Required Registered Nurse 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. #J-18808-Ljbffr Community Memorial Hospital, Inc.