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 6and 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.Education:* Bachelor's degree along with current RN DC license is required. However, an Associate's degree in Nursing with five years of bedside nursing experience can be used in lieu of the Bachelor's degree requirement. Familiarity using a personal computer including word processing and spreadsheets is required. Knowledge of reimbursement models (commercial, managed care, Medicare) is preferred.Experience:* Three to five years experience as a clinical nurse in an acute care setting. Prior experience in a hospital or office type setting preferred, prior experience as a Case Manager. Knowledge of MS Office Suite required. Insurance/payer experience preferred/prior utilization review experience preferred. Proficiency in Allscripts, MCG and InterQual preferred.Certification/Registration/Licensure:* Licensure as a registered nurse in the District of Columbia is required.About MedStar HealthMedStar 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.
Associated topics: bsn, cardiothoracic, coronary, infusion, intensive, mhb, nurse, nurse rn, recovery, unit