Utilization Review RN Registered Nurse
Posted on Apr 17, 2019 by MedStar Franklin Square Medical Center
General Summary of Position
Collaborates with the physician, nurse case manager, social worker, and other members of the health care team to meet individualized patient outcomes. Performs pre-admission, concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers.
- EDUCATION: Valid RN license in the State of Maryland; Bachelor's degree in Nursing preferred.
- EXPERIENCE: 5 years clinical experience in an acute care setting; 2 years experience in utilization management preferred.
- LICENSE/CERT/REG: ABQAURP certification preferred. NAHQ certification preferred.
- SKILLS: Verbal and written communication skills. Basic computer skills preferred.
Primary Duties and Responsibilities
- Actively participates in ongoing professional enrichment and educational opportunities.
- Collaborates with and assists the nurse case manager and social worker to meet the patients' continuing health needs in a high quality, cost effective manner by identifying patients in need of case management. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient, LOS insurance and discharge needs.
- Collects quality improvement data in accordance with approved indicators. Recognizes potential problems and makes referrals to quality improvement, risk management, safety, infection control, and other departments as appropriate.
- Confers and collaborates routinely with the physician advisor, division chiefs, and attending physicians to resolve problems regarding acuity and level of care.
- 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.
- Evaluates concurrent and retrospective denials for appeal opportunities. Generates appeal letters based on knowledge of clinical severity and intensity.
- Identifies insurance information, obtains authorization, communicates with financial counseling and assigns appropriate length of stay for admission.
- Implements strategies to avoid denials including potential denial notification to attending physician. Issues letter of non-coverage for Medicare or third party payers according to policies and procedures. Communicates utilization plans to case management team.
- Performs admission reviews and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on age specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment for services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources.
- Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings.
- Utilizes research methods to collect, tabulate, and analyze data in collaboration with the case management team, medical staff, and hospital performance improvement initiates. Implements strategies to correct or modify trends seen through data analysis and outcome monitoring.
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.