Utilization Review RN

Utilization Review RN

Washington, DC

• Salary: $90,000 - 95,000
• Hybrid (4 days in the field/in-office, 1 day remote)
• Schedule: Mon-Fri 8-5pm EST

Responsible for the preauthorization initial and concurrent review of all inpatient, behavioral health, home health care services (skilled, non-skilled, private duty, behavioral home services) utilizing internal criteria, InterQual, and/or national recognized criteria sets, clinical review of pediatric and young adult members for all in-patient stays, respite, home care, outpatient, rehabilitative therapy, durable medical equipment, and long term care services base don standardized criteria.

Qualifications

Minimum Education

Bachelor's Degree (Required)

Minimum Work Experience

3 years of sound medical/surgical, home health care, pediatric and/or behavioral health experience (required)

2 years experience in utilization revie in a managed care environment (required)

Required Skills/Knowledge

Proficiency with word processing and spreadsheets

Ability to handle multiple complex assignments

Strong analytical, critical thinking and problem solving

Required Licenses and Certifications

Registered Nurse DC License Upon Hire (Required)

Certification in utilization review (preferred)

Job Functions Essential job duties:

• Demonstrates accuracy in use of InterQual, CMS or other approved internal guidelines.
• Demonstrates compliance with authorization timelines base on assessment of past due cases.
• Demonstrates compliance in case closure.
• Demonstrates scores of at least 80% on inter-rate reliability testing for all InterQual assigned modules.
• Organizes utilization management within designated time frames to determine medical necessity and appropriateness of care.

Other job duties:

• May perform other duties in addition to those outlined in this job description.