RN Utilization Review Nurse
Posted on Apr 17, 2019 by MedStar Family Choice
Responsible for UM reviews for inpatient hospital stays,pre-certification reviews, ER reviews, and pharmacy reviews.
Valid RN license in the State of Maryland; Bachelor's degree preferred.
3 years Utilization Management experience and case management; 5 years diverse clinical experience. 3 years acute inpatient care clinical experience.
Valid RN license in the State of MD; CCM (Certified Case Manager) preferred.
Knowledge, Skills & Abilities
Ability to use computer to enter and retrieve data.
Primary Duties and Responsibilities
1. Actively develops and manages complex case management cases and develops individualized plans of care according to NCQA guidelines.
2. Acts as a liaison to MedStar Family Choice contracted vendors to facilitate care. Identifies gaps in contracted services and develops a plan to access care.
3. Acts as an advocate while assisting members to coordinate and gain access to medical, psychiatric, psychosocial and other essential services to meet their healthcare needs. Authorizes and monitors covered services according to policy.
4. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
5. Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.
6. Demonstrates skill and flexibility in providing coverage for other staff.
7. For assigned Disease Management program, develops strategies, an assessment, and evaluation/goal tool according to NCQA standards. Utilizes NCQA guidelines to manage and document interactions for the program. Responsible for verifying that assigned program utilizes up-to-date standards in the medical community. Keeps informed about disease processes, treatment modalities, and resources.
8. Identifies and reports potential coordination of benefits, subrogation, third party liability, worker's compensation cases, etc. Identifies quality, risk, or utilization issues to appropriate MedStar personnel.
9. Identifies inpatients requiring additional services and initiates care with appropriate providers. Demonstrates emphasis on quality patient care during the pre admission and/or concurrent review process. Authorizes services according to MedStar Family Choice policy.
10. Initiates contact with providers to obtain clinical information to facilitate approval or pending of pre-certification requests, inpatient stays and retrospective reviews.
11. Maintains current knowledge of MSFC benefits and enrollment issues in order to accurately coordinate services.
12. Maintains timely and accurate documentation in the IS system per Case Management policy.
13. Monitors utilization of all services for fraud and abuse.
14. Participates in staff meetings, Care Management meetings, Special Needs Forums, work groups, etc. as assigned. Provides input, completes assignments, and shares new findings with other staff.
15. Performs other duties as assigned.
16. Performs pharmacy reviews and documents in PBMs system when assigned.
17. Performs telephonic ACD line coverage for case management needs.
18. Performs telephonic inpatient utilization review services which includes: assessment, planning, coordinating, and implementation. Monitors for timely provision of services. Assists hospital case management staff with discharge planning.
19. Performs utilization reviews of ER visits when assigned. Makes referrals to CM as needed.
20. Sends thorough reviews to Physician Advisor as appropriate. Coordinates review decisions and notifications, per policy, COMAR guidelines for timely decisions and responses and NCQA guidelines.
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.