RN Utilization Review Nurse

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
• Bachelor's degree in Nursing preferred

Experience

• 3-4 years Experience in acute care setting required
• 2 years experience in case management insurance utilization review or related required

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 required
• CCM - Certified Case Manager 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.