What You'll Do
As a Registered Nurse in Utilization Management, you will conduct initial and concurrent clinical reviews using evidence-based tools such as Interqual to assess the appropriateness of patient care levels and medical necessity. You will collaborate with providers, case managers, and financial services teams to ensure accurate documentation and timely authorizations, supporting seamless patient care transitions.
You will monitor utilization management holds, track billing issues, and review unplanned readmission reports to identify opportunities for process improvement. Your role includes notifying patients and families of care level determinations, supporting discharge appeals, and managing denial responses and appeal activities in alignment with regulatory standards.
You will analyze outcome data and contribute to performance improvement initiatives by reporting trends to leadership. You will also assist in educating internal stakeholders and refining clinical documentation through structured query processes. Adherence to departmental workflows and productivity benchmarks is expected, along with adaptability to evolving policies and procedures.
Requirements
Candidates must hold an Associate’s degree in Nursing and possess an active New York State Registered Nurse license or a valid compact state license. A minimum of three years of acute care hospital experience is required. Licensure must be maintained in good standing from the date of hire.
Proficiency with clinical review platforms is essential, including experience with Interqual. Familiarity with healthcare databases such as SharePoint, eRecord, ePARC, and Cobius is strongly preferred. A Bachelor of Science in Nursing (BSN) is an advantage but not mandatory.
Benefits
This full-time, on-site position offers a compensation range of $80,923 to $105,208 annually, with actual salary determined by experience, education, and internal equity. The role supports organizational goals around accountability, integrity, and equitable patient care within a mission-driven academic health system.
The organization is committed to inclusion and does not discriminate on the basis of age, race, gender identity, disability, national origin, religion, sexual orientation, veteran status, or any other protected characteristic, in accordance with federal, state, and local laws.
