Staff Nurse – Quality

About the role

The Staff Nurse – Quality provides utilization management for the Long‑Term Acute Care Hospital (LTACH) at NYC Health + Hospitals/Carter. Acting as a bridge between clinicians, patients and payers, the nurse ensures that services are medically necessary, appropriate, and delivered efficiently.

Key responsibilities

• Review patient medical records and clinical data for concurrent and retrospective utilization reviews using InterQual LTACH and NYS DOH Medicaid criteria.
• Document concise clinical summaries and level‑of‑care decisions in the EPIC electronic health record.
• Ensure compliance with CFR Title 42, Section 482.30 regulations governing Medicare and Medicaid services.
• Collaborate with interdisciplinary teams, case managers and physicians to facilitate smooth transitions of care and reduce avoidable hospital days.
• Communicate findings to healthcare providers and insurance payers to manage costs and optimize patient outcomes.

Required profile

• Current Registered Nurse (RN) license.
• Experience in acute, sub‑acute or LTACH settings.
• Knowledge of Medicare/Medicaid utilization review processes and relevant regulatory standards.
• Ability to interpret and apply InterQual and state Medicaid criteria.
• Proficiency with EPIC EMR documentation.

Required skills

• Utilization Management
• InterQual LTACH criteria
• NYS DOH Medicaid criteria
• EPIC electronic health record
• Regulatory compliance (CFR Title 42 Section 482.30)