Utilization Reviewer (RN)- Full Time Days 8 AM - 4 PM, Atlantic Health Newton/Hackettstown/Chilton Medical Center

Job description

Utilization Reviewer (RN) – Emergency Department Atlantic Health System – Newton, Hackettstown & Chilton 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.