RN Utilization Review Specialist - Weekend Shifts & Collaboration

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

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