Job Description

Under general supervision of the Director of Case Management and Utilization Management manager, following established policies and procedures, the Senior UR Nurse utilizes clinical knowledge and expertise to interpret medical criteria, medical policy and benefit information. Monitors adherence to the MWHC utilization management plan to ensure the effective and efficient use of hospital services and monitors the appropriateness of MWHC admissions and continued stays. The Senior Utilization Review nurse leads the Utilization Review staff, including but not limited to: monitoring daily workloads and case assignment, develops and delivers initial and ongoing systems and process training, auditing, coaching, and oversight of the operations to ensure all UR contract requirements and business initiatives are completed successfully and timely. Senior UR RN will be responsible for a owning a small caseload. Coordinates with physicians, UR nurses, Clinical Resource Management (CRM) Case Managers and Utilization Management team, and other disciplines within the care team including outside agencies. Assists to effectively and efficiently complete comprehensive Clinical reviews, collaborate with the discharge planning team to decrease length of stay. Oversees the day-to-day operations of the utilization review process, ensuring that all patients receive appropriate levels of care in a timely and cost-effective manner. Acts as a resource who mentors, educate and supports the UR nurses and the front office staff. This position includes meeting the needs and providing services to all age groups-infancy through geriatrics, as well as providing services for the culturally diverse population MedStar Washington Hospital Center serves.
Education

• Bachelor\'s degree required
• Associate degree in Nursing with five years of bedside nursing experience can be used in lieu of the Bachelor degree requirement.

• 5-7 years of broad clinical experience in the acute care setting required
• Experience in case management, quality management and utilization management experience preferred

• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia required
• Oversees the utilization review process for all patients, including conducting reviews and coordinating care with other healthcare professionals and making recommendations for treatment plans.
• Provides professional expertise as a vital member of the interdisciplinary team to ensure that patients receive the most appropriate and cost effective care. Collaborates with interdisciplinary team in Identifying barriers that may result in delays in discharge and develops strategies to minimize; communicates successful strategies with the team.
• Maintains accurate and up-to-date records of all utilization review activities, including patient assessments, treatment plans and progress reports. Actively contributes, participates and follows through on interventions identified in Department daily reports.
• Acts as a resource for other members of the utilization review team, providing guidance and support as needed. Ensures all front office and Patient Financial Services and Central Financial Clearance issues and payor requests are addressed timely to avoid denials.
• Participates in ongoing training and professional development opportunities to stay current on best practices and new developments in utilization management.
• Provides accurate and timely Utilization Management functions while continuously looking for ways to improve our processes.
• Timely and accurate determination and notification of authorization, and appeals requests.
• Reviews Initial, concurrent, and retro authorizations cases according to established medical guidelines.
• Monitors the daily activity of Utilization reviews for consistency, and correctness in the applicable regulatory, and department standards. Performs random and quarterly audits of utilization review nurses work, discuss the outcome of audits with the UM manager and work with the UM manager to provide education as appropriate.
• Participates in the development and standardization of improved
• Successfully completes 2-3 preceptor assignments per year, following established educational plans and guidelines and providing insight and suggestions for improvement. Regularly reports progress of new associates to their manager, and may actively participate in planning and follow-up meetings regarding associate progress.
• Exemplifies staff relations, and holds utilization management staff accountable for conformity with the standards in all activities
• Provides details of education needs, and pathway improvement needs by report to UM Manager, and department Director.
• Assists with departmental projects and other functions such as assigned to support department operations and/or assist with UM related issues that may arise.

Medstar Health