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 an acute care setting required
2 years experience in case management insurance ultilization review or related preferred
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.
This position has a hiring range of
USD $89,065.00 – USD $162,801.00 /Yr.
Sidnie
Registered Nurse
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In addition to your salary, MedStar Health offers a comprehensive healthcare package (including medical, dental and vision subject to eligibility requirements) and other benefits. The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by MedStar Health. MedStar Health is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
The hiring range is the range MedStar Health, in good faith, believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on work experience, education and/or skill level, etc. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in MedStar Health’s sole discretion unless and until paid and may be modified at MedStar Health’s sole discretion, consistent with the law.
SPECIALTIES:
Utilization Review & Management (UR/UM)
