Utilization Review Nurse: Emergency Dept

Department/Unit: Care Management/Social Work

Work Shift: Day (United States of America)

Salary Range: $71,612.39 - $

• Utilization management and quality screening for assigned patients.
• Delay management, including removal of delays and documentation of delays.
• Apply MCG criteria to monitor appropriateness of admissions and continued stays, documenting findings based on departmental standards.
• Identify clinical documentation improvement opportunities and contact the appropriate department.
• Identify at‑risk populations using approved screening tools and follow established reporting procedures.
• Monitor length of stay (LOS) and ancillary resource use, taking actions to achieve continuous improvement.
• Refer cases and issues to the Medical Director and Triad Team in compliance with departmental procedures, and follow up as indicated.
• Communicate covered day reimbursement certification for assigned patients; discuss pay‑or criteria and resolve problems with payors as needed.
• Use quality screens to identify potential issues and forward information to the Quality Department.
• Demonstrate proper use of MCG and documentation requirements through case review and inter‑rater reliability studies.
• Collaborate with the healthcare team and appropriate departments to manage care across the continuum of care, ensuring communication with the Triad Team and the healthcare team.
• Maintain complete confidentiality of patient information and provide information and in‑services as necessary to physicians and ancillary staff.

• Contribute to a compassionate and caring environment for patients, families, and colleagues through displays of kindness and active listening.
• Recognize that each employee’s work is valuable and contributes to the success of the mission.
• Demonstrate excellence in daily work and actively participate in performance and quality improvement activities to enhance customer/patient satisfaction.
• Exhibit positive service‑excellence skills to patients, visitors, and coworkers by greeting others in a friendly manner and keeping them informed about progress, delays, and changes.
• Demonstrate effective teamwork by interacting positively with colleagues, fostering a collaborative environment, initiating open communication, conveying positive intent, and offering assistance.
• Contribute to a safe and secure environment by following established procedures and protocols.
• Demonstrate stewardship with responsible use of resources, maintaining a clean environment, starting work on time, and being cost‑conscious.
• Demonstrate respect for individual differences by acknowledging strengths, appreciating, and responding to unique backgrounds, spiritual, personal, and cultural differences.

• Registered nurse with a New York State current license.
• Associate degree required;
  Bachelor’s degree preferred.
• Minimum of three years clinical experience in an assigned service.
• Recent experience in case management, utilization management, and/or discharge planning/home care in a high‑volume, acute‑care hospital preferred. PRI and Case Management certification preferred.
• Assertive and creative problem‑solving, critical thinking skills, systems planning, and patient care management.
• Self‑directed with the ability to adapt in a changing environment.
• Basic knowledge of computer systems with skills applicable to utilization review processes.
• Excellent written and verbal communication skills.
• Working knowledge of MCG criteria and ability to implement and utilize.
• Understanding of inpatient versus outpatient surgery and ICD‑10 coding.
• Working knowledge of Medicare regulatory requirements and managed‑care plans.

• Ability to work independently and demonstrate organizational and time‑management skills.
• Strong analytic, data management, and PC skills.

• Infant (0–12 months)
• Preschool (1–4 years)
• School age (5–12 years)
• Adolescent (13–17 years)
• Adult (18–64 years)
• Older Adult (65+ years)

• Regularly required to stand, walk, use hands to probe, handle or feel items, reach with hands and arms, speak and hear.
• Occasionally required to…