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RN, BSN Utilization Review Nurse - Hospital

CareNational Healthcare Services • Buffalo, NY

Posted 5 days ago

Job Snapshot

Travel - None
Experience - 2 to 3 years
Degree - 4 Year Degree
$70,000.00 - $77,000.00 /Year
Insurance, Healthcare - Health Services, Managed Care
Health Care, Insurance, Nurse
Relocation - No


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Job Description

Utilization Review Nurse (RN, BSN) - Hospital
Buffalo, NY

Job Summary:

The Utilization Review Nurse is responsible for utilization management, utilization review, or concurrent/retrospective review of the patient’s care.  The UR Nurse ensures appropriate level of care through comprehensive concurrent review for medical necessity of outpatient observation and inpatient stays and the utilization of ancillary services, following evaluation of medical guidelines and benefit determination. Generally work is self-directed and not prescribed.  The Utilization Management Nurse works under the direct supervision of the Case Management department manager.

Position Description:

As a Utilization Review Nurse you will utilize your clinical skills to provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.  You will assist the attending physician and the case manager in identifying appropriate options for the level of care that will assist the patient in achieving optimum stability of health.  Interact with patients, case managers, physicians, and benefit administrators to determine medical status, type of immediate care needed and future care needs.  Perform Medicare, Medicaid or other sponsoring health benefit organization reviews of patients to be cared for in the outpatient or acute care settings.

You will obtain the information necessary to assess a patient's clinical condition, identify ongoing clinical care needs and ensure that patients receive services in the most optimal setting to effectively meet their needs.  Facilitate the delivery of services to patients and families through effective utilization of available resources.   You will evaluate the options and services required to meet the patient’s health needs, in support and collaboration with case & disease management interventions.  You will perform prospective, concurrent & retrospective review of inpatient, outpatient, ambulatory & ancillary services requiring clinical review.   Proactively work with physicians, case managers, clinical resource management, and payer organizations to identify, prevent, or appeal concurrent payment denials. Perform concurrent review to assure appropriateness of admission, continued inpatient/acute rehabilitation/SNF status, and discharge using established InterQual guidelines. 

Make referrals as indicated to case management, disease management, or behavioral health.  Collaborate with the Disease Management, Quality Management, and Case Management departments in the development of protocols and guidelines designed to standardize care practice and delivery. 


Job Requirements

 Background Profile:

  • Current unrestricted state Registered Nurse (R.N.) license.
  • Bachelors of Science in Nursing (B.S.N.) is required.
  • Roughly 2-3 years acute care clinical experience.
  • Around 2-3 years of utilization management or utilization review experience, can be from hospital or health plan setting.
  • Must have strong skills in medical assessment / medical record review.
  • Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
  • Knowledge of InterQual and Milliman criteria and other guidelines for medical necessity, setting and level of care, and concurrent patient management.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data entry.

The Reward:

Work with an exceptional organization focused exclusively on promoting the health care and quality of life for its members.  The forward-looking health plan has a demonstrated passion for finding innovative ways to enhance member’s ability to manage their own health.


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