Utilization Review Nurse
GENERAL SUMMARY 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 and 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. MINIMUM REQUIREMENTS EDUCATION Bachelor of Science in Nursing is required. Familiarity using a personal computer including word processing and spreadsheets is required. Knowledge of reimbursement models (commercial, managed care, Medicare) is preferred. PRIOR 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.