This role focuses on utilization review for emergency department admissions and continued stay reviews, using clinical criteria to determine medical necessity and appropriate admission status. The nurse reviews electronic medical records, communicates with emergency physicians by phone, and documents findings for authorization and payer review. It is a remote position that requires virtual collaboration and regular schedule flexibility.
Key Responsibilities
- Review emergency department admissions and concurrent stays for medical necessity using InterQual or MCG criteria.
- Evaluate electronic medical records to support evidence-based utilization decisions.
- Participate in telephone discussions with emergency department physicians regarding documentation and admission status.
- Enter clinical review findings into systems for submission to insurance companies for authorization.
- Analyze utilization patterns, trends, and potential inappropriate use of healthcare resources.
- Work collaboratively in a remote environment using virtual communication tools.
Required
- Current and unrestricted RN license.
- At least 3 years of clinical experience in an acute care setting such as emergency room, critical care, or medical/surgical nursing.
- At least 2 years of utilization management experience in acute admission and concurrent reviews.
- Intermediate experience with InterQual and/or MCG criteria within the last 2 years.
- Experience reviewing medical records in an electronic medical record (EMR) system.
- Proficiency with Microsoft Office and basic Excel.
Preferred
- At least 5 years of clinical experience in an acute care setting such as emergency room, critical care, or medical/surgical nursing.
- At least 3 years of utilization management experience in the hospital setting.
- BSN.
- Case management certification such as CCM, ACM, CMCN, or CMGT-BC.
Benefits & Perks
- Remote work arrangement.
- Shift options including 8-, 10-, or 12-hour schedules within the stated coverage window.
- Weekend-only full-time option available.
- Structured collaboration with emergency physicians and insurance authorization workflows.
- Background check and drug screen are covered by the employer.