MedStar Southern Maryland Hospital Center

RN Utilization Review

MedStar Southern Maryland Hospital Center • $89K — $162K *
Clinton, MD 20735In-Person
Healthcare
Less than 5 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Associate's degree in Nursing required; Bachelor's preferred.
  • 3-4 years in an acute clinical care setting required.
  • 2 years of Case Management, Insurance UR, or related experience preferred.
  • RN licensure in Maryland or Compact State required.
  • CCM certification preferred.

Responsibilities

  • Conducts admission concurrent and retrospective case reviews to ensure quality patient care.
  • Strives to meet departmental goals and adhere to organizational policies and quality standards.
  • Collaborates with medical and ancillary staff to meet patients' healthcare needs cost-effectively.
  • Performs medical record reviews and ensures timely communication with third-party payors.
  • Implements strategies to avoid potential denials by engaging with key stakeholders.
  • Handles non-coverage ABN and MOON letters as per organizational guidelines.
  • Participates actively in IDRs, Length of Stay, and other meetings as per hospital policy.
  • Identifies potential risks to patient care and communicates with appropriate departments.

Benefits

  • Opportunities for professional development and continuing education.
  • Collaborative work environment with interdisciplinary team collaboration.
  • Engagement in hospital-wide initiatives to enhance patient care quality.
  • Access to in-service training and formal educational settings.
Full Job Description
**Must be local to the DC/MD region with acute Utilization Review RN experience**

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 the acute clinical care setting required
  • 2 years Case Management insurance UR or related experience preferred

Licenses and Certifications
  • RN - Registered Nurse - State Licensure and/or Compact State Licensure in the State of Maryland 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.

This position has a hiring range of

USD $89,065.00 - USD $162,801.00 /Yr.

About MedStar Southern Maryland Hospital Center

MedStar Southern Maryland Hospital Center is a medical facility located in Clinton, Maryland. It is a 192-bed acute care hospital that provides a range of services including emergency care, cardiology, cancer care, orthopedics, and women's health. The hospital is part of the MedStar Health system, which is the largest healthcare provider in Maryland and the Washington, D.C. region. MedStar Southern Maryland Hospital Center is committed to providing high-quality, compassionate care to its patients and improving the health of the communities it serves.
Learn more about MedStar Southern Maryland Hospital Center
Size
1,200 employees
Industry
Healthcare
* Ladders Estimates

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