Utilization Review Nurse
7 days ago
MedStar Health is seeking a skilled RN Utilization Review Specialist to join our team. This role will be responsible for conducting admission, concurrent, and retrospective case reviews to ensure appropriate admit status and level of care by utilizing nationally approved guidelines.
Key Responsibilities- Conducts admission, concurrent, and retrospective case reviews to meet hospital objectives of high-quality patient care in the most efficient way
- Strives to meet department goals, adheres to organizational policies, procedures, and quality standards
- Complies with rules and regulations set forth by governmental and accrediting agencies
- Collaborates with medical staff, physician advisor, social workers, and other ancillary hospital disciplines to meet patients' healthcare needs in the most cost-effective way
- Performs patients' medical record reviews, documents pertinent information, and communicates with third-party payors in a timely fashion to ensure proper hospital reimbursement and eliminate unnecessary denials
- Implements strategies to avoid potential denials by communicating with all key stakeholders, including attending physicians
- Actively participates in IDRs, Length of Stay, and other meetings as per hospital policies
- Identifies potential risks pertaining to patients' care and communicates with appropriate hospital disciplines, including risk management, quality, safety, and infection control
- Serves as a resource to the healthcare team by educating them through in-services, staff meetings, and formal educational settings in areas of utilization management
- Demonstrates current knowledge of State and Federal regulatory requirements as it pertains to the utilization review process
- Identifies dynamics of neglect/abuse and reports to the appropriate in-house departments and governmental agencies
- Associate's degree in Nursing required
- Bachelor's degree in Nursing preferred
- 3-4 years of experience in acute care setting required
- 1-2 years of experience in case management, insurance UR/or related experience preferred
- RN licensure and/or Compact State Licensure in the District of Columbia or the state of Maryland depending on work location
- CCM certification preferred
- Excellent problem-solving skills and ability to exercise independent judgment
- Business acumen and leadership skills
- Strong verbal and written communication skills with ability to effectively interact with all levels of management, internal departments, and external agencies
- Working knowledge of various computer software applications
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