RN Utilization Review- PRN Weekends

MedStar Health; Columbia (MD); On-site; USD 59,000 - 98,000; Full time

Job summary

MedStar Health in Columbia, MD is seeking an experienced Utilization Review professional. The role requires acute care UR experience, RN licensure, and the ability to cover four weekend shifts per month plus in-person training.

You will work with physicians, social workers, and payors to ensure appropriate admission status and efficient care. The candidate collaborates across disciplines, reviews records, communicates to prevent denials, and contributes to policy compliance and quality

Qualifications

• 3-4 years of acute care setting experience is required.
• 1-2 years in case management, insurance UR, or related experience preferred.
• RN license in the District of Columbia or Maryland is required upon hire.
• CCM certification is preferred upon hire.

Responsibilities

• Conducts admission concurrent and retrospective reviews to determine admit status and level of care.
• Collaborates with medical staff, physician advisor, social workers, and other disciplines for cost-effective care.
• Reviews medical records and communicates with payors to ensure proper reimbursement and minimize denials.
• Implements strategies to avoid denials by coordinating with key stakeholders.
• Participates in IDRs and Length of Stay meetings as per hospital policy.
• Identifies risks in patient care and escalates to risk mgmt, quality, safety, and infection control.
• Educates care teams on utilization management through in-services and training sessions.
• Keeps knowledge current on state and federal regulations for utilization review.
• Identifies neglect/abuse indicators and reports to appropriate departments.

Skills

Problem solving

Business acumen

Verbal & written communication

Computer skills

Education

Associate's degree in Nursing

Bachelor's degree in Nursing preferred

RN license (state) required

CCM certification preferred

Job description

About the Job

***This position requires an individual to have acute Utilization Review experience and must be able to work 4 weekend shifts a month. You must also be available to train consistently in-person, which may include some weekday shifts***

General Summary of Position

Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing the nationally approved guidelines. Collaborates with medical staff and ancillary hospital disciplines to ensure high-quality patient care in the most efficient way.

Primary Duties and 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.
• Identifies potential risks pertaining to patients' care and communicates with appropriate hospital discipline including risk management quality safety and infection control.
• Serves as a resource to the health care team by educating the health care team through in-services staff meetings and formal educational settings in areas of utilization management.
• Demonstrate 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.

Minimal Qualifications

Education

• Associate's degree in Nursing required and
• Bachelor's degree in Nursing preferred

Experience

• 3-4 years 3 years experience in acute care setting required and
• 1-2 years 2 years experience in case management insurance UR/or related experience preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure In the District of Columbia or the state of Maryland depending on work location Upon Hire required and
• CCM - Certified Case Manager Upon Hire preferred

Knowledge Skills and Abilities

• 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.

This position has a hiring range of USD $42.82 - USD $71.16 /Hr.