Utilization Review Nurse

Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors.

Bargaining Unit:

UUP

Job Summary:

The Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Utilization Review Nurse.

The Utilization Review (UR) Nurse is responsible for performing clinical reviews to determine the medical necessity, appropriateness, and level of care for hospital admissions and continued stays. The UR Nurse applies evidence-based criteria (e.g., MCG, CMS) to support utilization decisions and collaborates with the interdisciplinary team, payers, and Case Managers to ensure timely and appropriate care transitions while minimizing denials and delays.

Key Responsibilities 

• Perform timely initial and continued stay reviews using established guidelines (MCG, CMS criteria).
• Document clinical findings and level of care determinations in the EMR and UR tracking systems.
• Submit reviews and clinical documentation to insurance payers as required.
• Collaborate with payers to obtain authorizations for admission, continued stay, and post-acute care.
• Participate in peer-to-peer and appeal processes when necessary.
• Partner with Case Managers and Social Workers for Care Coordination and discharge planning.
• Escalate cases with delays or denials appropriately.
• Ensure compliance with CMS, NYS DOH, Joint Commission, and hospital policies.
• Support audits, denial reviews, and quality improvement initiatives.

Required Qualifications:

• New York State Registered Nurse Licensure.
• Graduate of an accredited school of nursing.  
• Current Patient Review Instrument (PRI) Certification.
• 3-years acute care clinical nursing experience.
• Computer proficiency in Microsoft Word, Excel, PowerPoint. 
• Strong interpersonal, communication, administrative, and organizational skills.
• Or, a satisfactory equivalent combination of experience, education and training to the above.

Preferred Qualifications:

• Bachelor of Science Degree in Nursing preferred.
• 1 year of experience in Utilization Review or Case Management.
• CCM, ACM, or Utilization Review Certification.   
• MCG or InterQual training. 

Work Schedule:

Monday to Friday; 9:00am to 5:00pm (Full-Time)

Salary Grade/Rank:

Salary Range:

Commensurate with experience and qualifications

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 info@goer.ny.gov.

Equal Employment Opportunity Statement:

SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws.

Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply.

If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at ada@downstate.edu