Registered Nurse (RN) - Utilization Review
SUNY Downstate Medical Center
Brooklyn, NY
days
Sign-On Bonus

Utilization Review Nurse

The Department of Care Management at SUNY Downstate Health Sciences University is seeking a full-time Utilization Review Nurse. The successful candidate will: * Complete and send initial clinical reviews within 48-hours of admission for medical necessity and appropriate level of care to all applicable payors via Care Management Module, CarePort. * Complete and send every 3-days, continuous stay reviews for patients outside of their ELOS, due to changes in medical status in order to justify medical necessity for a continued stay. * Perform precertification reviews to establish medical necessity, appropriateness of services, and compliance with regulatory standards, established medical policy, community standards, and the members plan documents. * Perform concurrent and retrospective evaluation of inpatient hospitalizations to establish medical necessity, appropriateness of services, and discharge planning needs; coordinates with the medical team to ensure clinically appropriate determinations. * Apply clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care, forwarding all cases that do not meet these policies and guidelines, to the Medical Director. * Identify and suggest alternative solutions including appropriate levels of care delivery or need for negotiations when indicated. * Identify, investigate, and report to the medical team, possible quality of care issues discovered during concurrent or precertification reviews. * Participate in clinical rounds when applicable, quality improvement projects, continuing education, and medical management programs as required. * Provide consistent and accurate case documentation in EMR. * Act as a liaison to members, participants, providers of care, and when appropriate, to payors. * Perform other duties as assigned. Required Qualifications: * Bachelor of Science in Nursing. * Nursing clinical knowledge and expertise. * Prior hospital and/or community-based Care Management and Utilization Review experience. Preferred Qualifications: Work Schedule: Variable Days; 8:00am to 4:00pm 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 Governor's Office of Employee Relations at (518) 474-6988 or via email at [email protected]. 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, individuals with disabilities and members of underrepresented groups are encou