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Review and evaluate electronic medical records for emergency department admissions to ensure medical necessity using clinical criteria. Participate in telephonic discussions with physicians and transmit clinical review information to insurance companies for authorization.
Responsibilities
Review and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteria
Apply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resources
Participate in telephonic discussions with emergency department physicians relative to documentation and admission status
Enter clinical review information into system for transmission to insurance companies for authorization
Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources
Qualifications
Required
Current and unrestricted RN license
At least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
At least 2 years utilization management experience in acute admission and concurrent reviews
Intermediate level experience with InterQual and/or MCG criteria within the last two years
Proficiency in medical record review in an electronic medical record (EMR)
Experience in Microsoft Suite including Office and basic Excel
Ability to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needs
Passing score(s) on job-related pre-employment assessment(s)
Preferred
At least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursing
At least 3 years utilization management experience within the hospital setting
Bachelor's of Science in Nursing (BSN)
Case Management Certifications such as Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), Case Management, Board Certified (CMGT-BC)
Expectations
Comfortable with remote work arrangements and virtual collaboration tools
Physical demands include extended periods of sitting, computer use, and telephone communication
Netsmart is proud to be an equal opportunity workplace and is an affirmative action employer, providing equal employment and advancement opportunities to all individuals. We celebrate diversity and are committed to creating an inclusive environment for all associates. All employment decisions at Netsmart, including but not limited to recruiting, hiring, promotion and transfer, are based on performance, qualifications, abilities, education and experience. Netsmart does not discriminate in employment opportunities or practices based on race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, national origin, age, physical or mental disability, past or present military service, or any other status protected by the laws or regulations in the locations where we operate.
Netsmart desires to provide a healthy and safe workplace and, as a government contractor, Netsmart is committed to maintaining a drug-free workplace in accordance with applicable federal law. Pursuant to Netsmart policy, all post-offer candidates are required to successfully complete a pre-employment background check, including a drug screen, which is provided at Netsmart’s sole expense. In the event a candidate tests positive for a controlled substance, Netsmart will rescind the offer of employment unless the individual can provide proof of valid prescription to Netsmart’s third party screening provider.
If you are located in a state which grants you the right to receive information on salary range, pay scale, description of benefits or other compensation for this position, please use this form to request details which you may be legally entitled.
All applicants for employment must be legally authorized to work in the United States. Netsmart does not provide work visa sponsorship for this position.
Netsmart's Job Applicant Privacy Notice may be found here.
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