RN Utilization Review; PRN in Washington, DC

Position: RN Utilization Review (PRN)

General Summary of Position

Conducts admission concurrent and retrospective case reviews to ensure appropriate admit status and level of care by utilizing 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
• Conduct admission concurrent and retrospective case reviews to meet hospital objectives of high-quality patient care in the most efficient way.
• Strive to meet department goals, adhere to organizational policies, procedures, and quality standards; comply with rules and regulations set forth by governmental and accrediting agencies.
• Collaborate with medical staff, physician advisors, social workers, and other ancillary hospital disciplines to meet patients' health care needs in the most cost‑effective way.
• Perform 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.
• Implement strategies to avoid potential denials by communicating with all key stakeholders including attending physician.
• If necessary, prepare non‑coverage ABN, MOON letters, and other appropriate documents as per organizational, governmental, and accrediting organizations' policies and regulations.
• Actively participate in IDRs, Length of Stay, and other meetings as per hospital policies.
• Identify potential risks pertaining to patients' care and communicate with appropriate hospital disciplines including risk management, quality, safety, and infection control.
• Serve as a resource to the health care team by educating the 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.
• Identify dynamics of neglect/abuse and report 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 utilization review required.

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.
Hiring Range

USD $89,065.00 – $ per year.
Seniority Level

Not applicable.
Employment Type

Full‑time.
Job Function

Health Care Provider.
Industries

Hospitals and Health Care.
Location

Arlington, VA;
Alexandria and Fairfax, VA areas. Salary range: $60,522.00 – $ (posted 1 week ago).
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