Utilization Review Nurse | Buffalo, NY

Key Responsibilities:

• Perform prospective, concurrent, and retrospective reviews of inpatient admissions and continued hospital stays to ensure appropriateness of level of care based on established criteria (e.g., InterQual, Milliman) and payer/Medicare/Medicaid requirements.
• Review clinical documentation and collaborate with physicians and care teams to clarify/optimize admission status, length of stay, transition/discharge planning and post‐acute care.
• Work with admissions/registration, case management, nursing leadership and physicians to determine proper level of care (e.g., inpatient vs observation) and to support timely and safe patient transitions.
• Monitor daily hospital census, identify high risk/complex cases, and coordinate with discharge planners and case managers for smooth transitions to post‑acute settings (e.g., home health, skilled nursing facility, rehab).
• Act as clinical liaison with payers/insurance for authorization, appeals, and documentation of medical necessity; communicate with physicians, coding, billing and compliance departments as needed.
• Maintain up‑to‑date knowledge of payer policies, federal/state regulations (CMS, Medicare/Medicaid), case‑mix/index issues, DRG assignment and reimbursement implications.
• Maintain accurate and timely documentation of all review activities (acceptances/denials, level of care decisions, provider communication) in hospital UR software or electronic medical record (EMR).
• Identify process or documentation improvement opportunities (e.g., physician documentation, physician orders, discharge planning delays), recommend and implement quality improvement initiatives.
• Represent the Utilization Review department in hospital committees (e.g., Utilization Review Committee, Patient Flow, Quality Improvement) and provide education/training to physicians/nursing/case management on medical necessity, admission criteria, avoidable length of stay issues.
• Ensure compliance with hospital policies, regulatory standards (Joint Commission, CMS), contractual obligations with payers, and internal audit requirements.
• Participate in data tracking and reporting (e.g., avoidable days, length of stay metrics, denied days, payer appeals) and present trends to leadership.
• Assist in developing/maintaining utilization management tools, protocols and criteria (e.g., updates to InterQual or equivalent).

Qualifications:

Education & Licensure:

• Current, unrestricted Registered Nurse (RN) license in the applicable state.
• Bachelor of Science in Nursing (BSN) preferred (or ability to obtain within specified time).
• Basic Life Support (BLS) certification required.

Experience:

• Minimum of 2‑5 years of acute care nursing experience (med/surg, ICU, telemetry, etc.) in a hospital setting.
• Previous experience in utilization review, case management, discharge planning, or care coordination preferred.
• Knowledge of medical necessity criteria (e.g., InterQual or Milliman) preferred.
• Familiarity with payer reimbursement, hospital admission/discharge processes, DRG/case mix index, and regulatory/compliance guidelines.