Job Description:
• Conduct hospital admission reviews to determine medical necessity and appropriate patient status
• Conduct continued stay reviews using approved clinical criteria and guidelines
• Evaluate clinical documentation for accuracy, completeness, and compliance with payer and regulatory requirements
• Apply evidence-based criteria such as InterQual® and/or MCG®
• Communicate review findings and recommendations to physicians, case management staff, and leadership
• Collaborate with Physician Advisors regarding complex cases or cases not supported by criteria
• Assist with denial prevention activities and accurate documentation
• Perform other duties as assigned
• Work collaboratively with physicians, case managers, revenue cycle staff, and interdisciplinary care teams to facilitate appropriate patient status determinations and optimize reimbursement while supporting quality patient care
Requirements:
• Graduate of an accredited school of nursing
• Current, unrestricted Registered Nurse (RN) license
• Minimum five (5) years of acute care nursing experience in a hospital setting
• Minimum two (2) years of recent hospital-based or health plan utilization review experience
• Experience with acute admission reviews and continued stay reviews
• Proficient in multiple Electronic Health Records and case management systems
• Strong communication skills; communicates clearly and concisely, verbally and in writing
• Ability to thrive in a fast-paced environment and adapt to frequently changing business needs
• Ability to work independently with minimal supervision
• PRN position requiring a minimum of forty (40) hours per month when hours are available
• At least sixteen (16) required monthly hours must be worked on weekend shifts
• Ability to work four- or eight-hour shifts during 7 a.m.–7 p.m. hours
• Availability must be submitted thirty (30) days in advance
• Required to work two of six organization-recognized holidays each calendar year
• Must maintain flexibility and communicate availability according to department scheduling practices
• Must follow attendance and call-off policies
• Ability to perform physical activity that may include lifting up to 25 pounds
• Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), or Case Management Board Certification (CMGT-BC) preferred
Benefits:
• PRN scheduling flexibility with additional hours potentially available based on departmental needs and employee availability