Utilization Review Nurse- Care Coordination Department
Job Location:
Poughkeepsie, NY - USA
Monthly Salary:
Posted:
Application Deadline:
Vacancies:
Job Summary
Northwell is the largest not-for-profit health system in the Northeast serving residents of New York and Connecticut with 28 hospitals more than 1000 outpatient facilities 22000 nurses and over 20000 physicians. Northwell cares for more than three million people annually in the New York metro area including Long Island the Hudson Valley Connecticut and beyond thanks to philanthropic support from our communities. Northwell is New York States largest private employer with over 104000 employees including members of Northwell Health Physician Partners who are working to change health care for the better.
Summary:
The Utilization Review Nurse is responsible for conducting timely accurate and comprehensive clinical reviews to ensure that patients receive the appropriate level of care in accordance with regulatory payer and organizational guidelines. The Utilization Review Nurse applies evidence-based criteria to evaluate medical necessity and collaborates with physicians and interdisciplinary team members to reduce denials and ensure compliance with CMS and payer regulations.
Responsibilities:
- Performs initial concurrent and discharge utilization reviews to determine the appropriate patient status (inpatient observation outpatient).
- Applies InterQual MCG or payer-specific criteria in accordance with CMS regulations and the Two-Midnight Rule.
- Collaborates with admitting providers to obtain timely admission orders and correct patient status when discrepancies arise.
- Ensures MOON IMN HINN (etc.) notices are issued and documented per policy.
- Conducts timely payer notifications with complete reviews and all supporting clinical documentation via fax or payer portal.
- Provides clinical updates and facilitates peer-to-peer reviews as required.
- Maintains documentation of all payer interactions in Cerner.
- Securely maintains all relevant login credentials for all payer portals.
- Demonstrates proficiency in navigating payer portals to efficiently retrieve and submit required data.
- Discusses cases with the attending MD when a clinical review does not meet inpatient medical necessity at the first-level review to obtain additional clinical information and documentation to support inpatient level of care; if the case still does not meet criteria sends it to the Physician Advisor for a second-level review.
- Forwards cases requiring secondary physician review to the appropriate resource (e.g. Physician Advisor).
- Resolves discrepancies at the time of review or escalates unresolved issues to the Physician Advisor and departmental leadership.
- Coordinates with the care team to change patient status as needed.
- Notifies the care team when a patient does not meet medical necessity per InterQual MCG guidelines or the Two-Midnight Rule and escalates appropriately.
- Adheres to all federal state payer and hospital compliance requirements related to utilization management.
- Maintains confidentiality of patient information in accordance with HIPAA.
- Meets productivity standards including review volume timeliness and documentation quality.
- Adheres to the standards outlined in the Nuvance Health Remote Work Program Policy when utilizing a hybrid work arrangement.
Maintains and models organization values.
Demonstrates regular reliable and predictable attendance.
Performs other duties as required.
Education Skills Experience:
Associates degree in nursing
3 years experience in acute care or subacute care Nursing
3 years experience as Utilization Management Nurse in an acute care or subacute care setting preferred.
PREFERRED: Bachelors degree or masters degree in nursing Current NYS RN License.
CCM/ACM Preferred
NYS PRI certification preferred; required within 60 days of hire. MCG Certification Preferred
Working Conditions
Derived Working Conditions
Essential:
* Significant manual skills / motor coord & finger dexterity
* Significant occupational risk
* Very Heavy effort. May exert up to 50 lbs. force
* Significant exposure to dirt odor noise human waste etc.
Company: Vassar Brothers Medical Center
Org Unit: 1190
Department: Care Coordination
Exempt: No
Hourly Rate: $48.49-$73.58
Required Experience:
IC
About Company
Our hospitals, medical practice and care centers are located throughout New York’s Hudson Valley and Western Connecticut. At every location, you’ll find excellent convenient care, a personalized approach, a connected team, and access to our network of doctors. Find care now.
