RN Utilization Review

4 months ago


Washington, United States MedStar Medical Group Full time

General Summary of Position
Under the direction of The Director of UM/Appeals assists in the administration of utilization functions, the Utilization Review Nurse, assesses patient insurance/status to facilitate appropriate completion of utilization review using payer specific criteria; uses Interqual and MCG to determine medical necessity and appropriateness of inpatient or observation status ; serves as communication liaison between registered nurse case managers, social workers, on-site reviewers, patient financial services, outpatient areas and registration; and performs all functions in accordance with all applicable laws, regulations and MedStar Washington Hospital Center's philosophy, policies and standards.

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 the department goals, adheres to organizational policies, procedures, and quality standards. Complies with rules and regulations set forth by the governmental and accrediting agencies.

Collaborates with medical staff, physician advisor, social workers, and other ancillary hospital disciplines to meet patients' health care needs in the most cost-effective way.

Performs patients' medical record reviews, document pertinent information and communicate 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 the key stakeholders including attending physician.

If necessary, non-coverage, ABN, MOON letters, and other appropriate documents as per organizational, governmental, and accrediting organizations policies and regulations.

Actively participates in IDRs, Length of Stay, and other meetings as per hospital policies.

Qualifications

Bachelors Degree in Nursing is required or Associates Degree with 5 years of bedside nursing experience can be used in lieu of Bachelors Degree Requirement. Recent experience in Utilization Review in a hospital setting is required.

This is a PRN position to help fill in as needed to include some weekends


This position has a hiring range of $41.98 - $71.68


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