Utilization Review Nurse

Job Summary:

The Utilization Review RN is responsible for utilization review, discharge planning and transitions in care, in collaboration with MAPMG rounder in acute or alternative settings of care.

Essential Responsibilities:

• Utilization Review. According to department policy, procedure and protocols, consistently apply and verbally communicate approved utilization review criteria and guidelines for services delivered in acute or alternative care settings.
• Eligibility and Benefit Verification. Confirm eligibility status and ensure the appropriate administration of benefits in accordance with department policies and procedures.
• Assessing Right Venue of Care with Hospitalist. Collaboration with Hospitalist to assess the appropriate level of care for patients (i.e., Medical Unit, Surgical Unit, Tele Unit, TCU, ICU) and post- (Home, Continuum or Community-based Services) hospitalization.
• Coordination of Care. Driving patient care plan through assuring daily plan is executed, and management of transitions and post-hospital care.
• Effective Discharge Planning. Prompt, clinically appropriate discharge planning beginning at time of admission.
• Variance Management. Timely steps in identification of delays in throughput, escalation to correct delays, and recording delays to identify patterns and trends that will require corrective actions.
• Quality Screening. Demonstrate competency to assess all aspects of care across the continuum for variations from quality and utilization standards.
• Performs other related duties as directed.

Includes Weekend On-Call Rotations Basic Qualifications: Experience

• Minimum one (1) year of experience as an RN in an acute care setting.

Education

• N/A

License, Certification, Registration

• This job requires credentials from multiple states. Credentials from the primary work state are required at hire. Additional Credentials from the secondary work state(s) are required post hire.
  
  

• Registered Nurse License (Virginia) within 6 months of hire AND Registered Nurse License (Maryland) within 6 months of hire

OR 

• Compact License: Registered Nurse within 6 months of hire

• Registered Nurse License (District of Columbia) within 6 months of hire
  
  

• Basic Life Support
  
  

Additional Requirements:

• Annually: Successful completion of PCC Assessment of Critical Skills. Passing score on inter-rater reliability.
• Ability to effectively communicate.
• Ability to conform to established policies and procedures.
• Ability to analytically problem solve and make decisions.
• Ability to tolerate and cope with ambiguity
• Ability to work as a team member.
• Proficiency in the use of applicable computer software.
• Demonstrated ability to effectively and clearly present information through the written word, to influence or persuade others through oral presentation in positive or negative circumstances, and to listen well.
• Demonstrated ability to write clearly, legibly, and effectively, to present ideas and document activities, to read and interpret written information.

Preferred Qualifications:

• Recent acute care, case management, or home health experience preferred.
• B.S.N. preferred.