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Utilization Review Nurse
Oswego Health
Oswego, NY, USA
USD 40.15-43.25 / hour
Posted on Jul 2, 2025
Job Title: Utilization Review Nurse Department: Case Management
Reports to: VP of Quality & Patient Safety Revision Date: 06/24/2025
Status: Non-Exempt
Job Summary
The Review Nurse will review all clinical cases according to regulations governing this activity, participation in the utilization review and denials management activities
Duties/Responsibilities
Graduate of an approved RN program, and current licensure in NYS required. Bachelor degree in preferred. Minimum of 5 years clinical experience required. Demonstrated competence in utilization review, quality improvement, general health care financial management, and computer skills preferred.
Working Conditions
Employee salary is based on commensurate experience and other qualifications.
About Oswego Health
The mission of Oswego Health is to provide accessible, quality care and improve the health of residents throughout Oswego County. As a nonprofit healthcare system established in 1881, Oswego Health is proud to be Oswego County’s largest private employer. More than 1,300 employees spread throughout its 18 locations, work for the Oswego Health system, which includes the 132-bed community Oswego Hospital, a 32-bed psychiatric acute-care facility with multiple outpatient behavioral health service locations, The Manor at Seneca Hill, a 120-bed skilled nursing facility, and Springside at Seneca Hill, an independent retirement community. The health system also operates Oswego Health Home Care, the only hospital-based certified home healthcare agency in the County, as well as two outpatient centers, including the Fulton Medical Center, offering urgent care, lab, medical imaging, physical therapy, and occupational health services, and the Central Square Medical Center, offering urgent care, lab, medical imaging, and physical therapy services. In addition, the healthcare system includes Oswego Health Medical Practice, a multi-specialty medical group offering the community accessible, high-quality healthcare. 100+ physicians and advanced practice providers offer an extensive array of services across CNY, including primary care and specialty care in the areas of orthopedics, cardiology, ENT, gastroenterology, breast care, general surgery, urology, and bariatrics.
EQUAL EMPLOYMENT OPPORTUNITY
Oswego Health is committed to providing equal opportunity in all employment-related matters, without regard to race (including traits historically associated with race), creed, color, religion, sex/gender, national origin, age, marital or familial status, disability, pregnancy-related condition, sexual orientation, gender identity, gender expression, transgender status, citizenship status, ancestry, arrest/conviction record, military or veteran status, domestic violence victim status, genetic predisposition or carrier status, reproductive health decision making, relationship or association with a member of a protected category, or any other legally protected characteristic. Decisions affecting your position including, but not limited to, recruitment, hiring, placement, promotion, transfer, compensation, benefits, training, tuition assistance, leaves of absence, disciplinary action, layoff/recall, and terminations will be made in accordance with this policy.
Reports to: VP of Quality & Patient Safety Revision Date: 06/24/2025
Status: Non-Exempt
Job Summary
The Review Nurse will review all clinical cases according to regulations governing this activity, participation in the utilization review and denials management activities
Duties/Responsibilities
- Demonstrates knowledge of the UR process by performance of complete and accurate evaluation, initiation and implementation of the UR plan, with modification as needed.
- Maintain a current Utilization Review Plan in accordance with state and federal regulations.
- Provide clinical supervision to professional or paraprofessional staff related to utilization review.
- Review of clinical records for timeliness and quality of documentation to ensure compliance with regulations governing clinical operation and provide feedback to clinicians and managers.
- Provide technical assistance, training and education to clinicians to assist in improving the quality of their documentation as well as to case managers for level of care determinations.
- Maintain accurate records of utilization review activities and provide reports to the appropriate individuals and committees.
- Attending committee meetings as appropriate and requested.
- Develop and implement quality monitoring such as utilization review screens and evaluation instruments in consultation with medical and other professional staff.
- Maintain familiarity with all regulations which affect the provision and documentation of clinical services (these include but are not limited to JACHO, DOH and CMS).
- Ensure compliance with the JCAHO national patient safety goals.
- Monitor policy and procedure compliance and committee oversight
- Participate in development and update of criteria specific to readmission, concurrent, focused and retrospective reviews as well as provide case managers with information regarding updates to UR functions.
- Coordinate prompt completion and verification of information for billing purposes and coordinate, process and track all reconsiderations and appeals to maximize reimbursement.
- Assist providers and finance division as requested for appeals, reconsideration or interpretation of the state and federal guidelines for UR.
- Process documents needed for level of care changes (ie. Denial, reinstatements) according to regulations for hospital and ALC patients.
- Perform other duties as required.
- Excellent written and oral communication, analytical, computer, and presentation skills required.
- Demonstrated high level of knowledge quality, clinically integrated networks, and care coordination.
- Ability to diagnose problems and drive appropriate solutions
- Professionalism and business acumen appropriate for working with senior executives, board members, employees, clients, physicians, guests, and volunteers.
- Strong analytical skills and ability to interpret and communicate data.
- Proficient in standard computer programs, including Microsoft Office Suite.
Graduate of an approved RN program, and current licensure in NYS required. Bachelor degree in preferred. Minimum of 5 years clinical experience required. Demonstrated competence in utilization review, quality improvement, general health care financial management, and computer skills preferred.
Working Conditions
- Extended periods of sitting, using standard office equipment including, but not limited to computers, phones, scanners, fax machines, printers, etc.
- Requires attendance of seminars, workshops, conferences when appropriate.
- Requires leading and/or attending staff and executive meetings.
- Occasionally requires assembling, using and maintaining all departmental equipment.
- Occasionally requires prolonged periods of standing and walking with the ability to lift, push or pull up to 15 lbs. using proper body mechanics.
- Actively participates in Quality Assurance programs and QAPI, in-service programs; completes department specific requirements/competencies; attends all mandatory classes as required; participates in meetings and committees as assigned.
- Complies with DOH requirements for annual health assessments and required immunizations.
Employee salary is based on commensurate experience and other qualifications.
About Oswego Health
The mission of Oswego Health is to provide accessible, quality care and improve the health of residents throughout Oswego County. As a nonprofit healthcare system established in 1881, Oswego Health is proud to be Oswego County’s largest private employer. More than 1,300 employees spread throughout its 18 locations, work for the Oswego Health system, which includes the 132-bed community Oswego Hospital, a 32-bed psychiatric acute-care facility with multiple outpatient behavioral health service locations, The Manor at Seneca Hill, a 120-bed skilled nursing facility, and Springside at Seneca Hill, an independent retirement community. The health system also operates Oswego Health Home Care, the only hospital-based certified home healthcare agency in the County, as well as two outpatient centers, including the Fulton Medical Center, offering urgent care, lab, medical imaging, physical therapy, and occupational health services, and the Central Square Medical Center, offering urgent care, lab, medical imaging, and physical therapy services. In addition, the healthcare system includes Oswego Health Medical Practice, a multi-specialty medical group offering the community accessible, high-quality healthcare. 100+ physicians and advanced practice providers offer an extensive array of services across CNY, including primary care and specialty care in the areas of orthopedics, cardiology, ENT, gastroenterology, breast care, general surgery, urology, and bariatrics.
EQUAL EMPLOYMENT OPPORTUNITY
Oswego Health is committed to providing equal opportunity in all employment-related matters, without regard to race (including traits historically associated with race), creed, color, religion, sex/gender, national origin, age, marital or familial status, disability, pregnancy-related condition, sexual orientation, gender identity, gender expression, transgender status, citizenship status, ancestry, arrest/conviction record, military or veteran status, domestic violence victim status, genetic predisposition or carrier status, reproductive health decision making, relationship or association with a member of a protected category, or any other legally protected characteristic. Decisions affecting your position including, but not limited to, recruitment, hiring, placement, promotion, transfer, compensation, benefits, training, tuition assistance, leaves of absence, disciplinary action, layoff/recall, and terminations will be made in accordance with this policy.