Utilization Review Nurse

SUNY Downstate Health Sciences University

Job Location:

Brooklyn, NY - USA

Monthly Salary: Not Disclosed

Posted on: 3 days ago

Vacancies: 1 Vacancy

Job Summary

	Are you looking to take your career to new heights with a leader in healthcare SUNY Downstate Health Sciences University is one of the nations leading metropolitan medical centers. As the only academic medical center in Brooklyn we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical a healthcare rating company for consumers among the top 5 leading U.S. medical schools for training doctors.
Bargaining Unit:	UUP
Job Summary:	The Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Utilization Review Nurse. The Utilization Review (UR) Nurse is responsible for performing clinical reviews to determine the medical necessity appropriateness and level of care for hospital admissions and continued stays. The UR Nurse applies evidence-based criteria (e.g. MCG CMS) to support utilization decisions and collaborates with the interdisciplinary team payers and Case Managers to ensure timely and appropriate care transitions while minimizing denials and delays. Key Responsibilities Perform timely initial and continued stay reviews using established guidelines (MCG CMS criteria). Document clinical findings and level of care determinations in the EMR and UR tracking systems. Submit reviews and clinical documentation to insurance payers as required. Collaborate with payers to obtain authorizations for admission continued stay and post-acute care. Participate in peer-to-peer and appeal processes when necessary. Partner with Case Managers and Social Workers for Care Coordination and discharge planning. Escalate cases with delays or denials appropriately. Ensure compliance with CMS NYS DOH Joint Commission and hospital policies. Support audits denial reviews and quality improvement initiatives.
Required Qualifications:	New York State Registered Nurse Licensure. Graduate of an accredited school of nursing. Current Patient Review Instrument (PRI) Certification. 3-years acute care clinical nursing experience. Computer proficiency in Microsoft Word Excel PowerPoint. Strong interpersonal communication administrative and organizational skills. Or a satisfactory equivalent combination of experience education and training to the above.
Preferred Qualifications:	Bachelor of Science Degree in Nursing preferred. 1 year of experience in Utilization Review or Case Management. CCM ACM or Utilization Review Certification. MCG or InterQual training.
Work Schedule:	Monday to Friday; 9:00am to 5:00pm (Full-Time)
Salary Grade/Rank:	SL-4
Salary Range:	Commensurate with experience and qualifications
Executive Order:	Pursuant to Executive Order 161 no State entity as defined by the Executive Order is permitted to ask or mandate in any form that an applicant for employment provide his or her current compensation or any prior compensation history until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time please contact the Governors Office of Employee Relations ator via email at .
Equal Employment Opportunity Statement:	SUNY Downstate Health Sciences University is an affirmative action equal opportunity employer and does not discriminate on the basis of race color national origin religion creed age disability sex gender identity or expression sexual orientation familial status pregnancy predisposing genetic characteristics military status domestic violence victim status criminal conviction and all other protected classes under federal or state laws. Women minorities veterans individualswith disabilities and members of underrepresented groups are encouraged to apply. If you are an individual with a disability and need a reasonable accommodation for any part of the application process or in order to perform the essential functions of a position please contactHuman Resources at

Required Experience:

Are you looking to take your career to new heights with a leader in healthcare SUNY Downstate Health Sciences University is one of the nations leading metropolitan medical centers. As the only academic medical center in Brooklyn we serve a large population that is among the most diverse in the world...

	Are you looking to take your career to new heights with a leader in healthcare SUNY Downstate Health Sciences University is one of the nations leading metropolitan medical centers. As the only academic medical center in Brooklyn we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical a healthcare rating company for consumers among the top 5 leading U.S. medical schools for training doctors.
Bargaining Unit:	UUP
Job Summary:	The Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Utilization Review Nurse. The Utilization Review (UR) Nurse is responsible for performing clinical reviews to determine the medical necessity appropriateness and level of care for hospital admissions and continued stays. The UR Nurse applies evidence-based criteria (e.g. MCG CMS) to support utilization decisions and collaborates with the interdisciplinary team payers and Case Managers to ensure timely and appropriate care transitions while minimizing denials and delays. Key Responsibilities Perform timely initial and continued stay reviews using established guidelines (MCG CMS criteria). Document clinical findings and level of care determinations in the EMR and UR tracking systems. Submit reviews and clinical documentation to insurance payers as required. Collaborate with payers to obtain authorizations for admission continued stay and post-acute care. Participate in peer-to-peer and appeal processes when necessary. Partner with Case Managers and Social Workers for Care Coordination and discharge planning. Escalate cases with delays or denials appropriately. Ensure compliance with CMS NYS DOH Joint Commission and hospital policies. Support audits denial reviews and quality improvement initiatives.
Required Qualifications:	New York State Registered Nurse Licensure. Graduate of an accredited school of nursing. Current Patient Review Instrument (PRI) Certification. 3-years acute care clinical nursing experience. Computer proficiency in Microsoft Word Excel PowerPoint. Strong interpersonal communication administrative and organizational skills. Or a satisfactory equivalent combination of experience education and training to the above.
Preferred Qualifications:	Bachelor of Science Degree in Nursing preferred. 1 year of experience in Utilization Review or Case Management. CCM ACM or Utilization Review Certification. MCG or InterQual training.
Work Schedule:	Monday to Friday; 9:00am to 5:00pm (Full-Time)
Salary Grade/Rank:	SL-4
Salary Range:	Commensurate with experience and qualifications
Executive Order:	Pursuant to Executive Order 161 no State entity as defined by the Executive Order is permitted to ask or mandate in any form that an applicant for employment provide his or her current compensation or any prior compensation history until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time please contact the Governors Office of Employee Relations ator via email at .
Equal Employment Opportunity Statement:	SUNY Downstate Health Sciences University is an affirmative action equal opportunity employer and does not discriminate on the basis of race color national origin religion creed age disability sex gender identity or expression sexual orientation familial status pregnancy predisposing genetic characteristics military status domestic violence victim status criminal conviction and all other protected classes under federal or state laws. Women minorities veterans individualswith disabilities and members of underrepresented groups are encouraged to apply. If you are an individual with a disability and need a reasonable accommodation for any part of the application process or in order to perform the essential functions of a position please contactHuman Resources at