Registered Nurse Utilization Coordinator - PRN
Company: MedStar Health
Posted on: June 12, 2021
- Job Summary
Collaborates with the physician, nurse case manager, social
worker, and other members of the health care team to meet
individualized patient outcomes. Performs pre-admission,
concurrent, and retrospective medical record reviews based on
approved screening criteria, knowledge of insurance coverage, and
communication with the third-party payers. Ensures medical
necessity determinations, service authorization and concurrent
denials are managed effectively and financially responsibly.
- Minimum Qualifications
Valid RN license in State of Maryland; Bachelor's degree in
5 years clinical experience in acute care setting.
CPR/BLS preferred. CCM and/or ACMA preferred.
- Knowledge, Skills & Abilities
Verbal and written communication skills. Basic computer skills
preferred. Diagnosis and problem-solving skills.
- Primary Duties and Responsibilities
Contributes to the achievement of established department goals
and objectives and adheres to department policies, procedures,
quality standards and safety standards. Complies with governmental
and accreditation regulations.
Actively participates in ongoing professional enrichment and
educational opportunities. Collaborates with and assists the nurse
case manager and social worker to meet the patients' continuing
health needs in a high quality, cost effective manner. Participates
in planning rounds as needed to address and communicate issues
related to acuity level of patient, LOS insurance and discharge
Collects quality improvement data in accordance with approved
indicators. Recognizes potential problems and makes referrals to
quality improvement, risk management, safety, infection control,
and other departments as appropriate.
Confers and collaborates routinely with the physician advisor,
division chiefs, and attending physicians to resolve problems
regarding acuity and level of care.
Evaluates concurrent and retrospective denials for appeal
opportunities. May generate appeal letters based on knowledge of
clinical severity and intensity.
Identifies insurance information, obtains authorization,
communicates with financial counseling and assigns appropriate
length of stay for admission.
Implements strategies to avoid denials including potential
denial notification to attending physician. Issues letter of
non-coverage for Medicare or third party payers according to
policies and procedures. Communicates utilization plans to case
Performs admission reviews and subsequent concurrent reviews to
determine the necessity for acute care by application of accepted
criteria based on age specific needs. Interacts with and assists
third party payer reviewers to facilitate appropriate care and
ensure payment for services. Performs concurrent and retrospective
reviews telephonically as required. Completes all forms and
documentation necessary to support appropriate utilization of
Serves as a resource to all staff in areas of utilization
review/management. Educates members of health care team through
in-services, staff meetings, orientation and formal educational
offerings. Utilizes research methods to collect, tabulate, and
analyze data in collaboration with the case management team,
medical staff, and hospital performance improvement initiatives.
Implements strategies to correct or modify trends seen through data
analysis and outcome monitoring.
- Performs other duties as assigned.
About MedStar Health
MedStar 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
Keywords: MedStar Health, Baltimore , Registered Nurse Utilization Coordinator - PRN, Other , Baltimore, Maryland
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