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.
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.