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Job description
About This Role
The Staff Nurse-Quality position at NYC Health and Hospitals involves managing the clinical review of services for patients entitled to Medicare and Medicaid benefits. This role is ideal for nurses who excel in utilization management and are committed to optimizing patient care.
Highlights
Pay: $112,775/year
Location: New York, NY
Facility: NYC Health + Hospitals/Carter
Department/Unit: NON PSRO UTILIZATION REVIEW
Schedule: Full-Time, Day shift
What You'll Do
Evaluate patient medical records and clinical data for medical necessity and appropriateness.
Conduct concurrent and retrospective reviews using InterQual LTACH criteria or NYS DOH Medicaid criteria.
Communicate with healthcare providers, patients, and insurance payers to manage costs and optimize care.
Submit clinical reviews to insurers for authorization of continued stay and reimbursement.
Complete Patient Review Instrument and update PRI data in EPIC for timely discharges.
Discuss medical status with physicians and ensure timely determinations from insurance companies.
Monitor potential service denials and manage appeals in compliance with guidelines.
Collaborate with interdisciplinary teams and case managers for smooth transitions of care.
Requirements
Experience:
3-5 years of clinical bedside experience
1-3 years in utilization review, case management, or managed care preferred
Licenses & Certifications:
Valid New York State RN License required
Additional Compensation
Annual education differential based on degree:
Bachelors in allied health discipline = $900
Masters in allied health discipline = $1,200
Bachelors of Science in Nursing (BSN) = $1,800
Masters of Science in Nursing (MSN) = $2,000
Doctorate in Education, Nursing Practice or PhD in Nursing (DNP) = $2,500
Annual certification differential ranging from $1,878 up to $4,878 for nationally recognized certifications.
Annual nursing experience differential ranging from $987 up to $8,190 for up to 10 years of experience.
Benefits
Comprehensive Health Benefits for employees working 20+ hours per week
Retirement Savings and Pension Plans
Paid Holidays and Vacation
Loan Forgiveness Programs for eligible employees
College tuition discounts and professional development opportunities
College Savings Program
Union Benefits for eligible titles
Multiple employee discount programs
Commuter Benefits Programs
About NYC Health and Hospitals
NYC Health + Hospitals is a leading healthcare provider committed to delivering exceptional patient care. The organization operates multiple facilities, including NYC Health + Hospitals/Carter, which is recognized for its quality medical and rehabilitative services.
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Worksite address
new york, NY, 10261, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.