Utilization Review Nurse- (12a-8a EST)

Responsible for utilization review work for emergency admissions and continued stay reviews.

Responsibilities

• Review electronic medical records of emergency department admissions and screen for medical necessity, using InterQual or MCG criteria.

• Participate in telephonic discussions with emergency department physicians relative to documentation and admission status.

• Enter clinical review information into system for transmission to insurance companies for authorization.

Qualifications
Required

• Current RN licensure 

• At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing 

• At least 2 years utilization management experience in acute admission and concurrent reviews 

• Intermediate level experience with InterQual and/or MCG criteria within the last two years 

• Proficiency in medical record review in an electronic medical record (EMR) 

• Experience in MS Office and basic Excel  

• Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs 

• Passing score(s) on job-related pre-employment assessment(s)

Preferred

• At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing 

• At least 3 years utilization management experience within the hospital setting 

• Bachelors of Science in Nursing 

• Proficient in InterQual/MCG criteria 

• Case Management Certification (CCM, ACM, CMCN, or CMGT-BC 

Expectations

• This job operates in a remote environment that must be private. This role routinely uses standard office equipment such as computers, phones, and printers.

• Hours will vary, including two weekends a month.

• Must be able to remain in a stationary position 50% of the time and constantly operate a computer.

• Frequently communicates with internal, external and executive personnel and must be able to listen and exchange accurate information.

Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.

Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.

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All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.

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