Nursing Utilization Review Specialist

1 week ago


Washington, United States MedStar Health Full time

About the Role:

We are seeking a skilled Nursing Utilization Review Specialist to join our team at MedStar Health. In this role, you will play a critical part in ensuring high-quality patient care by conducting admission, concurrent, and retrospective case reviews.

Job Summary:

The Nursing Utilization Review Specialist conducts thorough reviews of patients' medical records to ensure accurate and timely reimbursement. This includes analyzing medical documentation, identifying potential denials, and communicating with third-party payors to resolve issues efficiently.

Key Responsibilities:

  • Conducts admission, concurrent, and retrospective case reviews to identify areas for improvement and ensure compliance with nationally approved guidelines
  • Collaborates with medical staff, physician advisors, social workers, and other ancillary hospital disciplines to meet patients' healthcare needs in a cost-effective manner
  • Reviews patients' medical records, documents pertinent information, and communicates with third-party payors to ensure proper reimbursement and minimize unnecessary denials
  • Identifies potential risks related to patient care and communicates with appropriate hospital departments to address these concerns
  • Serves as a resource to the healthcare team by educating them on utilization management best practices through in-services, staff meetings, and formal educational settings
  • Maintains current knowledge of State and Federal regulatory requirements related to utilization review

Requirements:

  • Associate's degree in Nursing (Bachelor's degree preferred)
  • 3-4 years of experience in an acute care setting (2 years in case management, insurance, or utilization review preferred)
  • RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia required
  • CCM - Certified Case Manager certification is desirable

Skills and Qualifications:

  • Excellent problem-solving skills and ability to exercise independent judgment
  • Business acumen and leadership skills
  • Strong verbal and written communication skills
  • Working knowledge of computer software applications

Compensation: The salary range for this position is $87,318 - $157,289 per annum.



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