Utilization Review Nurse, PRN, Remote

Job title: Utilization Review Nurse, PRN, Remote in USA at Netsmart Company: Netsmart Job description: Job Description Summary Are you a detail-oriented and experienced RN with a passion for ensuring quality care and appropriate resource utilization? We’re seeking a Utilization Review Nurse to join our fully remote team. In this role, you’ll conduct utilization reviews for emergency admissions and continued stays, applying InterQual criteria to support clinical decision-making and ensure compliance with healthcare standards.As a key member of our Clinical Services team, you’ll collaborate with emergency department physicians, review electronic medical records, and contribute to the efficient delivery of care. This is a full-time, 40-hour-per-week position offering flexibility within a supportive and dynamic work environment.Note: Recent experience with InterQual is required. Experience with MCG is a plus.ResponsibilitiesReview and evaluate electronic medical records of emergency department admissions and screen for medical necessity using InterQual or MCG criteriaApply evidence-based clinical guidelines and criteria to assess and ensure proper utilization of healthcare resourcesParticipate in telephonic discussions with emergency department physicians relative to documentation and admission statusEnter clinical review information into system for transmission to insurance companies for authorizationReview, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resourcesQualifications RequiredCurrent and unrestricted RN licenseAt least 3 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursingAt least 2 years utilization management experience in acute admission and concurrent reviewsIntermediate level experience with InterQual and/or MCG criteria within the last two yearsProficiency in medical record review in an electronic medical record (EMR)Experience in Microsoft Suite including Office and basic ExcelAbility to thrive in a fast-paced, dynamic environment and adapt to frequent changing business needsPassing score(s) on job-related pre-employment assessment(s)PreferredAt least 5 years clinical experience in acute care setting in emergency room, critical care and/or medical/surgical nursingAt least 3 years utilization management experience within the hospital settingBachelor'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)Work Schedule RequirementsThis is a PRN position requiring a total of 48 hours per month.16 hours must be worked on the weekend per month, weekends are Sat/Sun.Required to work 4 hours on 4 Holidays per yearExpectationsComfortable with remote work arrangements and virtual collaboration toolsPhysical demands include extended periods of sitting, computer use, and telephone communicationNetsmart 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 scree