Pool Utilization Review Registered Nurse, Case Management, Per Diem, Shift Varies (Rotating Weekends)

The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical, financial and resource utilization. Coordinates with healthcare Team for optimal efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention and coordination to decrease avoidable delays denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry, Facilitates communication between payers, review agencies and healthcare team, Identify delays in treatment or inappropriate utilization and serves as a resource, Coordinates communication with physicians, Identify opportunities for expedited appeals and collaborates resolve payer issues and ensures, maintains effective communication with Revenue Cycle Departments. Estimated pay range for this position is $47.00 / hour depending on shift as applicable.

Degrees:

• Associates.

Licenses & Certifications:

• Registered Nurse.

Additional Qualifications:

• RNs hired prior to 2/2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN; however, required to complete the BSN within 3 years of hire.
• 3 years of hospital clinical experience preferred.
• Excellent written, interpersonal communication and negotiation skills.
• Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently.
• Strong analytical, data management and computer skills.
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
• Current working knowledge of payer and managed care reimbursement preferred.
• Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.
• Knowledgeable in local, state, and federal legislation and regulations, and ability to tolerate high volume production standards.

Minimum Required Experience: .

• BSN Required
• 3 years of Nursing experience with 1 year of Hospital or Payor Utilization Review experience required
• MCG Specialist Certification ISC/HRC required within 12 months of job entry date.