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.
Minimum 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 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 $60,632 - $101,899
Registered Nurse, Medicine 7 East (Georgetown)
MedStar Georgetown University Hospital's 7 East is a 14-bed General Medical-Surgical unit with continuous pulse oximetry monitoring. The Clinical Nurses on 7 East provide expert care for patients with complex, multisystem diagnoses. Contributes to the achievement of established department goals and ...
Rapid Response Registered Nurse (Georgetown)
MedStar Georgetown is currently hiring full-time nurses for the Rapid Response Team (RRT). Rapid Response Registered Nurse (Georgetown). The RRT is a team of nurses and advanced practiced providers who will ensure the management and implementation of advanced critical care nursing during acute patie...
Transplant Nurse, Pancreas Acquisition (MedStar Georgetown)
These functions are performed in accordance with all applicable laws and regulations and Georgetown University Hospital's philosophy, policies, procedures, and standards. Coordinates the complex management and education of patients pre and post-transplant. Maintains and reviews patient records, char...
Registered Nurse, Endoscopy Procedural (Georgetown)
The Endoscopy Unit at MedStar Georgetown is a high volume procedural department with 5 pre-procedural bays and 6 state-of-the-art procedural rooms. The Endoscopy nurse will assist expert physicians perform advanced therapeutic procedures such as Colonscopy, Endoscopy, ERCP, EUS, Single Balloon Enter...
PRN Group III/B Nurse - Medical/Surgical Intermediate Care Unit (S5-2) (Georgetown)
By joining our team at MedStar Georgetown University Hospital, you'll have the opportunity to work amongst passionate individuals making a difference in healthcare. PRN Group III/B - Medical/Surgical Intermediate Care Unit (S5-2) (Georgetown). Clinical Nurses on our 28-bed adult Medical-Surgical Int...
Operating Room Nurse -Full time nights (Georgetown)
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, safety standards, and MedStar SPIRIT Values. Practices within legal boundaries of nurse practice act and possesses a theoretical understanding of the unive...
Registered Nurse, PRN Group III - 5 Bles (Georgetown)
Standard Job Duty: Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, safety standards, and MedStar SPIRIT Values. Practices within legal boundaries of the nurse practice act and possesses a theoretical und...
Registered Nurse Medical Surgical C4-3 (Georgetown)
About MedStar Georgetown University Hospital’s C4-3 Medical-Surgical Unit. MedStarGeorgetown University Hospital's C4-3 is a 14-bed General Medical-Surgicalunit with continuous pulse oximetry monitoring. The Clinical Nurses on 7East provide expert care for patients with complex, multisystem diagnose...
Transplant Nurse - Pre-Kidney (Georgetown)
These functions are performed in accordance with all applicable laws and regulations and Georgetown University Hospital's philosophy, policies, procedures, and standards. Coordinates the complex management and education of patients pre and post-transplant. Maintains and reviews patient records, char...
Med Surg PRN Nurse Grp III (Georgetown)
RN - Registered Nurse - State Licensure and/or Compact State Licensure Current license as a Registered Nurse in the state or jurisdiction of the facility seeking employment, or Multistate Compact state or license eligible. Standard Job Duty: Contributes to the achievement of established department g...