Staff Nurse - Utilization Review (ED)

Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St. Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County. 

Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.

SUMMARY:

We are currently seeking a Staff Nurse to join our Utilization Management department for the Emergency Department 

This position is a 0.6 FTE (6 shifts/ pay period), 8-hour shifts, Days, with up to Every Other Weekend rotation.  Note: Note: Current weekend assignment is typically every 2-3 weeks however is subject to change based on staffing needs and may require up to Every Other Weekend coverage.

SPECIFIC RESPONSIBILITIES:

The Utilization Review (UR) Registered Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities. The RN conducts timely reviews of inpatient and outpatient medical records to determine the appropriateness of admissions, continued stays, and the level of care using established criteria and guidelines (e.g., InterQual, MCG). This role collaborates with healthcare providers, patients, payers, and internal departments to ensure quality care while optimizing resource utilization and controlling costs.

Assessment:

• Collects, reviews, and documents clinical data relevant to utilization management, including patient status, treatment plans, and healthcare utilization. Applies nationally recognized criteria (e.g., InterQual, MCG) to assess the appropriateness of services

Outcomes Identification:

• Identifies expected outcomes related to care transitions, resource use, and reimbursement to optimize patient health outcomes and reduce unnecessary utilization

Planning:

• Develops a utilization management plan by coordinating with clinical teams, payers, and discharge planners to support timely care progression and appropriate resource use

Implementation:

• Implements review processes to evaluate necessity and efficiency of services. Initiates communication with physicians and payers to resolve authorization issues and prevent delays in care

Evaluation:

• Continuously evaluates the appropriateness of hospital admissions, continued stays, and treatment plans in accordance with payer guidelines and evidence-based practice

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