About this opportunity
Northwell Health lists this Utilization Review Nurse- Care Coordination Department opportunity in poughkeepsie, New York. Review the employer’s description below for duties, qualifications and application requirements.
Job description
Description
nNorthwell is the largest not-for-profit health system in the Northeast, serving residents of New York and Connecticut with 28 hospitals, more than 1,000 outpatient facilities, 22,000 nurses and over 20,000 physicians. Northwell cares for more than three million people annually in the New York metro area, including Long Island, the Hudson Valley, Connecticut and beyond, thanks to philanthropic support from our communities. Northwell is New York State's largest private employer with over 104,000 employees - including members of Northwell Health Physician Partners - who are working to change health care for the better.
nSummary:
nThe Utilization Review Nurse is responsible for conducting timely, accurate, and comprehensive clinical reviews to ensure that patients receive the appropriate level of care in accordance with regulatory, payer and organizational guidelines. The Utilization Review Nurse applies evidence-based criteria to evaluate medical necessity and collaborates with physicians and interdisciplinary team members to reduce denials and ensure compliance with CMS and payer regulations.
nResponsibilities:
nnClinical Review & Level of Care Determination
n nnnPerforms initial, concurrent, and discharge utilization reviews to determine the appropriate patient status (inpatient, observation, outpatient).
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nnApplies InterQual, MCG, or payer-specific criteria in accordance with CMS regulations and the Two-Midnight Rule.
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nnCollaborates with admitting providers to obtain timely admission orders and correct patient status when discrepancies arise.
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nnEnsures MOON, IMN, HINN (etc.) notices are issued and documented per policy.
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n nnPayer Communication & Authorization Management
n nnnConducts timely payer notifications with complete reviews and all supporting clinical documentation via fax or payer portal.
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nnProvides clinical updates and facilitates peer-to-peer reviews as required.
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nnMaintains documentation of all payer interactions in Cerner.
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nnSecurely maintains all relevant login credentials for all payer portals.
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nnDemonstrates proficiency in navigating payer portals to efficiently retrieve and submit required data.
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n nnCollaboration with Clinical Team
n nnnDiscusses cases with the attending MD when a clinical review does not meet inpatient medical necessity at the first-level review to obtain additional clinical information and documentation to support inpatient level of care; if the case still does not meet criteria, sends it to the Physician Advisor for a second-level review.
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nnForwards cases requiring secondary physician review to the appropriate resource (e.g., Physician Advisor).
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nnResolves discrepancies at the time of review or escalates unresolved issues to the Physician Advisor and departmental leadership.
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nnCoordinates with the care team to change patient status as needed.
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nnNotifies the care team when a patient does not meet medical necessity per InterQual, MCG guidelines, or the Two-Midnight Rule and escalates appropriately.
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n nnCompliance & Performance Standards
n nnnAdheres to all federal, state, payer, and hospital compliance requirements related to utilization management.
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nnMaintains confidentiality of patient information in accordance with HIPAA.
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nnMeets productivity standards, including review volume, timeliness, and documentation quality.
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n nnHybrid Work Standards and Accountability
n nnAdheres to the standards outlined in the Nuvance Health Remote Work Program Policy when utilizing a hybrid work arrangement.
n nMaintains and models organization values.
nDemonstrates regular, reliable and predictable attendance.
nPerforms other duties as required.
nEducation Skills Experience:
nAssociate's degree in nursing
n3 years experience in acute care or subacute care Nursing
n3 years experience as Utilization Management Nurse in an acute care or subacute care setting preferred.
nPREFERRED: Bachelor's degree or master's degree in nursing Current NYS RN License.
nCCM/ACM Preferred
nNYS PRI certification preferred; required within 60 days of hire. MCG Certification Preferred
nWorking Conditions
nDerived Working Conditions
nEssential:
nnnSignificant manual skills / motor coord & finger dexterity
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nnSignificant occupational risk
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nnVery Heavy effort. May exert up to 50 lbs. force
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nnSignificant exposure to dirt, odor, noise, human waste, etc.
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n nCompany: Vassar Brothers Medical Center
nOrg Unit: 1190
nDepartment: Care Coordination
nExempt: No
nHourly Rate: $48.49-$73.58
nIt is Northwell Health's policy to provide equal employment opportunity and treat all applicants and employees equally regardless of age, race, creed/religion, color, national origin, immigration status, or citizenship status, military or veteran status, sexual orientation, sex/gender, gender identity, gender expression, height, weight, disability, pregnancy, genetic information or genetic predisposition or carrier status, marital or familial status, partnership status, victim of domestic violence, their or their dependent's sexual or other reproductive health decisions, or other characteristics protected by applicable law.
Worksite address
poughkeepsie, NY, 12600, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.