The Utilization Review Nurse primarily reviews emergency department patient cases to determine the medical necessity of admissions, continued stays, and level of care. This role works closely with physicians, nurses, and insurance representatives to support timely authorization, accurate documentation, and appropriate patient flow. It also contributes to quality improvement, compliance, and process updates within a fast-paced hospital setting.
Key Responsibilities
- Conduct case reviews to assess the appropriateness of admissions, continued stays, and level of care.
- Use clinical judgment and evidence-based guidelines to support medical necessity determinations.
- Coordinate with physicians, nurses, and other care team members to gather information and discuss care plans.
- Communicate with insurance providers to obtain authorizations and support payer compliance.
- Maintain detailed documentation of reviews, decisions, and communication with internal and external stakeholders.
- Prepare utilization review and compliance reports as needed.
- Participate in quality improvement efforts to improve emergency department efficiency and outcomes.
- Support patient throughput by monitoring census peaks and placement needs.
Required
- Active Illinois Registered Nurse (RN) license.
- Associate degree in Nursing.
- At least 3 years of clinical experience in an emergency department setting.
- Strong clinical assessment and critical thinking skills.
Preferred
- Bachelor’s degree in Nursing (BSN) or higher.
- Prior experience in utilization review or case management.
- Knowledge of InterQual and/or MCG criteria.
- Experience with electronic health record systems and utilization review software.
Benefits & Perks
- Competitive compensation within the posted pay range.
- Premium pay opportunities such as shift differential and on-call pay.
- Annual pay increases based on performance.
- Paid time off for eligible full-time and part-time employees.
- Medical, dental, vision, life, and disability benefits for eligible employees.
- Health savings and flexible spending account options.
- Defined contribution retirement plans with employer match.
- Educational assistance and career development support.