Job Description:
• Conduct hospital admission reviews to determine medical necessity and appropriate patient status (inpatient, observation, outpatient)
• 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
Requirements:
• Extensive acute care nursing experience and demonstrated expertise in utilization review within a hospital setting
• 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 frequent changing business needs
• Ability to work independently, needing minimal supervision
• 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
• 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
• Must work two of the six organization-recognized holidays each calendar year
• Must maintain flexibility and communicate availability according to department scheduling practices
• Must report to work as scheduled and follow attendance and call-off policies
Benefits:
• PRN scheduling with shift options of four or eight hours
• Additional hours may be scheduled based on departmental needs and employee availability