Utilization Review Nurse

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🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Netsmart

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1973

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

Netsmart is a leading provider of comprehensive EHR solutions tailored for a wide range of care settings, especially in behavioral health, addiction treatment, autism, geriatrics, and intellectual and developmental disabilities. The company offers a range of software products that streamline operations, enhance care coordination, and promote value-based care across healthcare communities. In addition to EHRs, Netsmart provides technology solutions for care coordination, telehealth, population health management, and revenue cycle management, aiming to support the delivery of integrated and person-centered care. Their solutions are used in a variety of sectors including human services, post-acute care, and public health, making Netsmart a significant player in the healthcare technology industry.

📋 Description

• Review and evaluate electronic medical records for emergency department admissions • Screen admissions for medical necessity using InterQual or MCG criteria • Apply evidence-based clinical guidelines to assess and ensure proper utilization of healthcare resources • Participate in telephonic discussions with emergency department physicians regarding documentation and admission status • Enter clinical review information into the system for transmission to insurance companies for authorization • Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources

🎯 Requirements

• Current and unrestricted RN license • At least 3 years of clinical experience in an acute care setting in emergency room, critical care and/or medical/surgical nursing • At least 2 years of 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 with Microsoft Suite, including Office and basic Excel • Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changes in business needs • Passing score(s) on job-related pre-employment assessment(s) • All applicants must be legally authorized to work in the United States • Must be able to complete a pre-employment background check, including a drug screen • Preferred: at least 5 years of clinical experience in an acute care setting • Preferred: at least 3 years of utilization management experience within a hospital setting • Preferred: Bachelor of Science in Nursing (BSN) • Preferred: Case Management certifications such as CCM, ACM, CMCN, or CMGT-BC • Physical ability to sit for extended periods, use a computer, and communicate by telephone

🏖️ Benefits

• Remote work arrangements • Virtual collaboration tools • Equal employment and advancement opportunities • Pre-employment background check and drug screen provided at Netsmart’s sole expense