Job Description

General Summary of Position
Under the direction of The Director of UM/Appeals assists in the administration of utilization functions, the Utilization Review Nurse, assesses patient insurance/status to facilitate appropriate completion of utilization review using payer specific criteria; uses Interqual and MCG to determine medical necessity and appropriateness of inpatient or observation status ; serves as communication liaison between registered nurse case managers, social workers, on-site reviewers, patient financial services, outpatient areas and registration; and performs all functions in accordance with all applicable laws, regulations and MedStar Washington Hospital Center's philosophy, policies and standards.

Primary Duties and Responsibilities

• Consistently meets baseline productivity standards minimum of 25 utilization reviews daily; but if more than 25 are assigned all must be completed on that day.
• Applies MCG criteria or InterQual and advanced clinical knowledge to determine medical necessity, appropriate level of care, appropriate resource utilization, optimal insurance coverage and timely discharge.
• Takes appropriate action when level of care determinations is not in alignment with clinical information, clinical criteria or third-party information.
• Validates admission and continuing stay criteria with third party payers and Attending Physicians.
• Collaborates daily with the CRM unit team to discuss patients ready for discharge, possible insurance issues, and patient status changes and identified barriers that might impact LOS.
• Maintains accurate, concise, and timely documentation in Allscripts or case management database and other WHC record-keeping systems according to Department and Hospital standard practice.
• Maintains current knowledge of clinical treatment modalities related to assigned patient populations, quality and clinical improvement strategies, and reimbursement issues.
• Identifies consistent actual and/or potential issues related to quality, length of stay and reimbursement, and communicates them to department leadership using established procedures.
• Assists with departmental projects and other functions as assigned to support department operations and/or assist with patient specific issues that may arise.
• Provides functional assistance to include:
• a) Working with case managers, social workers, management teams and other groups as necessary to identify and manage utilization issues that impact hospital revenues.
• b) Working collaboratively with Manager of Appeals/UM, Social Work and Director of CRM to problem solve core issues which may cause delays in hospital reimbursement.
• c) Making follow-up calls.
• d) Preparing written appeals to facilitate the denials process.
• Escalates issues to utilization leadership as required.
• Participates in committees as required.

Minimum Qualifications
Education

• Bachelor's degree in Nursing required
• Associate degree in Nursing with five years of bedside nursing experience can be used in lieu of the Bachelor's degree requirement.

Experience

• 3-4 years as a clinical nurse in an acute care setting required
• Prior experience as a Case Manager required
• Prior experience in a hospital or office type setting preferred
• Prior utilization review experience preferred
• Insurance/payer experience preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia required

Knowledge, Skills, and Abilities

• Familiarity using a personal computer including word processing and spreadsheets
• Knowledge of reimbursement models (commercial, managed care, Medicare) is preferred.
• Proficiency in Allscripts, MCG and InterQual preferred.
• Knowledge of MS Office Suite

This position has a hiring range of $87,318 - $149,094

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