Utilization Review Nurse
2 weeks ago
Are you a skilled Utilization Review Nurse seeking a flexible PRN role that includes weekend shifts? MedStar Health Washington Hospital Center is currently looking for a PRN UR Nurse to provide coverage as needed, including weekends.
Position Summary
Under the supervision of the Director of Utilization Management/Appeals, the Utilization Review Nurse plays a crucial role in managing utilization functions. This position involves evaluating patient insurance status to ensure the accurate execution of utilization reviews based on payer-specific criteria. The nurse will utilize Interqual and MCG guidelines to assess medical necessity and determine the appropriateness of inpatient or observation status. Additionally, this role serves as a vital communication link among registered nurse case managers, social workers, on-site reviewers, patient financial services, outpatient departments, and registration.
Key Responsibilities
1. Conducts admission, concurrent, and retrospective case evaluations to align with hospital objectives aimed at delivering high-quality patient care efficiently.
2. Works diligently to achieve departmental goals while adhering to organizational policies, procedures, and quality standards. Ensures compliance with regulations set forth by governmental and accrediting bodies.
3. Collaborates effectively with medical staff, physician advisors, social workers, and other healthcare professionals to address patients' healthcare needs in a cost-effective manner.
4. Reviews patients' medical records, documents relevant information, and communicates with third-party payers promptly to secure appropriate hospital reimbursement and minimize unnecessary denials.
5. Implements strategies to prevent potential denials by engaging with all key stakeholders, including attending physicians.
6. Prepares necessary documentation such as non-coverage notices, ABN, MOON letters, and other relevant documents in accordance with organizational, governmental, and accrediting agency policies and regulations.
Qualifications
- Associate's degree in nursing is required.
- Bachelor's degree in nursing is preferred.
- A minimum of 3 years of experience in an acute care environment is required.
- At least 2 years of experience in Case Management, Insurance, Utilization Review, or a related field is strongly preferred.
- Active DC Nursing License is mandatory.
- CCM Certification is preferred.
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