Utilization Review Nurse
4 weeks ago
As a Utilization Review Nurse at Medstar, you will play a crucial role in ensuring high-quality patient care while maintaining efficiency. Your primary responsibility will be to conduct admission, concurrent, and retrospective case reviews to verify the appropriateness of patient care and level of treatment. You will collaborate with medical staff and other hospital disciplines to provide the best possible care for our patients.
Key Responsibilities
• Conduct thorough case reviews to ensure compliance with nationally approved guidelines and hospital objectives.
• Collaborate with medical staff, social workers, and other hospital disciplines to meet patients' healthcare needs in a cost-effective manner.
• Perform medical record reviews, document pertinent information, and communicate with third-party payors to ensure proper hospital reimbursement and minimize unnecessary denials.
• Develop strategies to prevent potential denials by communicating with key stakeholders, including attending physicians.
• Prepare and implement non-coverage, ABN, MOON letters, and other necessary documents as per organizational, governmental, and accrediting organization policies and regulations.
• Participate in IDRs, Length of Stay, and other meetings as per hospital policies.
• Identify potential risks related to patient care and communicate with appropriate hospital disciplines, including risk management, quality, safety, and infection control.
• Serve as a resource to the healthcare team by educating them through in-services, staff meetings, and formal educational settings on utilization management best practices.
• Stay up-to-date with current knowledge of State and Federal regulatory requirements related to the utilization review process.
• Identify and report dynamics of neglect/abuse to the appropriate in-house departments and governmental agencies.
Requirements
• Associate's degree in Nursing required; Bachelor's degree in Nursing preferred.
• 3-4 years of experience in an acute care setting required; 2 years of experience in case management, insurance, utilization review, or related fields preferred.
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia or the State of Maryland depending on work location required.
• CCM - Certified Case Manager 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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