Sep 22, 2022

Registered Nurse - Utilization Review/Quality Assurance Sr. Coordinator

  • Upstate Nursing
  • Syracuse, NY, USA

Job Description

Registered Nurse - Utilization Review/Quality Assurance Sr. Coordinator

Job no: 73000
Department: Utilization Management
Employer: State of New York
Payroll Title: T H Util. Review/Quality Assur. Sr Coord., NSSL4
Bargaining Unit: UUP (State University Professional Services Unit)
Salary: Commensurate with Qualifications
Work type: Full-time
Location: Syracuse
Categories: Registered Nurses

Job Summary: The Registered Nurse - Utilization Review/Quality Assurance Sr. Coordinator will be responsible for providing clinical information to managed care companies as requested for hospitalized patients both concurrently and retrospectively per hospital policy and procedure to prevent denial of payment. Responsible for working through the appeal process in an effort to overturn payment denial decisions. Will assist/participate in special utilization studies/projects and in the development of new programs/processes. Responsible for working with the Case Management to ensure the appropriate application of Interqual Criteria at the time of admission and for continued stay and for processing level of care changes. Responsible for issuing notices of non-coverage per hospital policy and procedure and for taking the lead in the discharge appeal process. Reviews high cost outlier accounts for appropriate charges, rounds with the interdisciplinary teams, attends committee meetings as requested. Works closely with Clinical Data and Finance staff and must maintain current knowledge of federal regulations and all CMS activities.
Minimum Qualifications:

NYS Licensed/Registered (or eligible) RN, Bachelors Degree in Nursing (or healthcare related field) and a minimum of three years RN post licensure nursing experience, or Associates Degree in Nursing and five years RN post licensure nursing experience required. Excellent communication and customer service skills required for interface with health care payers, regulatory agencies and other health care related entities.

Preferred Qualifications:

Candidates with a minimum of 3 years of acute care RN experience, strong computer skills and knowledge of Community, State & Federal laws, regulations and resources preferred. Utilization Review/Managed Care/Quality Assurance experience preferred. Experience in the application of InterQual Adult and Pediatric Acute Care Screening Criteria preferred. Experience interfacing with health care payers/regulatory agencies preferred.

Work Days:

Monday-Friday, 8:00 am - 4:30 pm with occasional weekends and evenings.

Message to Applicants: This position is primarily remote with some onsite responsibilities.
Recruitment Office: Human Resources
Executive Order: Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor's Office of Employee Relations at (518) 474-6988 or via email at