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Case Mgr/Utilization Review Nurse Washington Hospital Center job in Washington at MEDSTAR HEALTH

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Case Mgr/Utilization Review Nurse Washington Hospital Center at MEDSTAR HEALTH

Case Mgr/Utilization Review Nurse Washington Hospital Center

MEDSTAR HEALTH Washington, DC (On Site) Full-Time
The Emergency Department Case Manager / Utilization Review Nurse collaborates with all members of the Emergency Department/Clinical Resource Management (CRM) team to review and coordinate the admission of Emergency Department patients; and is available on a rotating basis on weekends, evenings, and holidays with other staff to provide onsite services for Utilization Review or Case Management. Initiates appropriate clinical pathways based upon diagnosis and serves as a resource person for utilization management purposes as well as partnering with the Social Worker Team to promote smooth transitions for discharge planning.
  • Bachelor's degree along with current District of Columbia RN license Required
  • Experience
    • 1-2 years working in case management and/or emergency department case management Required
    • Licenses and Certifications
      • RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia Required
      • CPR - Cardiac Pulmonary Resuscitation Required
      • BLS - Basic Life Support Required
      • CCM - Certified Case Manager Preferred
      • Knowledge, Skills, and Abilities
        • Knowledge of Medicare, Medicaid, and Third Party payor programs.
        • Collaborates with the Emergency Department providers, clinical nurses, and other clinical ancillary staff to assist with the initial patient assessment/review and high-risk screen for the purpose of Utilization Review (UR) Management.
        • Initiates a UR screening tool to ensure screening is based on present criteria and communicates to other members of the CRM team or Resource Center according to procedure.
        • Assists with referrals to Outpatient, Home Health and/or other agencies as indicated by a Provider order and engages the assistance of the Social Work Team as needed for patient through put.
        • Communicates with third party payers to assist with pre-certification, PCP referrals, and waivers.
        • Completes in a timely manner, UM admission/observation stay criteria review to obtain
        • Identifies high-risk re-admission patients, and communicates, as needed, for UM purposes.
        • Refers individual patient reviews that do not meet status criteria to MWHC Physician Advisor as needed.
        • Readily distinguishes between acute, intermediate and skilled levels of care.
        • Refers concurrent utilization problems/issues to the PA for review.
        • Advises the provider of the appropriate commercial insurer requirements, such as Medicare, Medicaid, and/or second opinion requirement.
        • Maintains current clinical records according to department policy, professional standards, and prepares monthly statistical reports as designated by Leadership.
        • Performs data collection such as tracking (for data analysis) number of CM consults from Healthcare Team, patients referred/transferred directly to another facility set up by CRM, patients referred to Home Health Services & Readmission data; and tracking (for performance improvement) number of level of care changes (OBS vs. INPT) identified by UR RN, potential admissions diverted safely home, pay for performance activities, and clinic referrals.
        • Facilitates the

Recommended Skills

  • Basic Life Support
  • Cpr
  • Case Management
  • Certified Case Manager
  • Certified Nurse Practitioner
  • Clinical Works
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Job ID: 15902_62179a02dff966a6

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