Utilization Reviewer (RN) - Emergency Department, Full Time, Days, 8 AM - 4 PM, Atlantic Health Overlook Medical Center

Utilization Reviewer (RN)

• Emergency Department Atlantic Health System
• Overlook Medical Center Full-Time | Days | Monday-Friday | 8:00 AM
• 4:00 PM Atlantic Health System is seeking a Full-Time Utilization Reviewer RN to support Emergency Department operations at Overlook Medical Center.

The Utilization Reviewer is responsible for conducting real-time medical necessity reviews and level-of-care determinations for patients presenting to the Emergency Department. This role serves as a key liaison between clinical teams and utilization management to ensure appropriate patient status assignment, regulatory compliance, and optimal patient throughput.

Responsibilities:

Perform concurrent medical necessity reviews for Emergency Department patients utilizing MCG and/or InterQual criteria. Evaluate admission, observation, and level-of-care determinations in accordance with CMS, payer, and organizational guidelines. Collaborate with Emergency Department physicians, hospitalists, physician advisors, and care management teams to support timely patient placement decisions. Provide education and guidance regarding CMS Observation Rules, Two-Midnight Rule, and documentation requirements. Identify potential denial risks and compliance concerns and escalate as appropriate. Communicate patient status determinations and pertinent clinical information to inpatient Utilization Review staff for continuity of care. Participate in departmental quality initiatives, data collection, reporting, and performance improvement activities related to utilization management and patient throughput. Maintain current knowledge of regulatory and payer requirements impacting utilization review practices.

Required:

Graduate of an accredited School of Nursing. Current New Jersey Registered Nurse (RN) License in good standing. Strong clinical assessment and critical thinking skills. Excellent communication and interdisciplinary collaboration abilities.

Preferred:

Bachelor of Science in Nursing (BSN). Previous Case Management, Utilization Review, or Care Coordination experience. Experience utilizing MCG and/or InterQual criteria. Knowledge of CMS regulations, Observation Status requirements, and Utilization Management principles. Prior Emergency Department, Acute Care, Case Management, or Clinical Documentation experience.