Utilization Review Nurse

Job Locations US-CA-Oakland
Req No
Production Coding
Contract to Permanent (Full Time)




Under the direction of The Director of UM/Appeals assists in the administration of utilization functions, the Utilization  Review Nurse, assesses patient insurance/status  to facilitate appropriate completion of utilization review using payer specific criteria; uses Interqual and MCG to determine medical necessity and appropriateness of inpatient or observation status ; serves as  communication liaison between registered nurse case managers, social workers, on-site reviewers, patient financial services, outpatient areas and registration; and performs all functions in accordance with all applicable laws, regulations and MedStar Washington Hospital Center’s philosophy, policies and standards.


Peak Health Solutions, an AMN Healthcare company, is an EEO/AA/Disability/Protected Veteran EmployerWe encourage minority and female applicants to apply



  1. Consistently meets baseline productivity standards of 35 utilization reviews daily.
  2. Applies MCG criteria or InterQual and advanced clinical knowledge to determine medical necessity, appropriate level of care, appropriate resource utilization, optimal insurance coverage and timely discharge.
  3. Takes appropriate action when level of care determinations are not in alignment with clinical information, clinical criteria or third party information.
  4. Validates admission and continuing stay criteria with third party payers and Attending Physicians.
  5. Collaborates on a daily basis with the CRM unit team to discuss patients ready for discharge, possible insurance issues, and patient status changes and identified barriers that might impact LOS.
  6. Maintains accurate, concise, and timely documentation in Allscripts or case management database and other WHC record-keeping systems according to Department and Hospital standard practice.
  7. Maintains current knowledge of clinical treatment modalities related to assigned patient populations, quality and clinical improvement strategies, and reimbursement issues.
  8. Identifies consistent actual and/or potential issues related to quality, length of stay and reimbursement, and communicates them to department leadership using established procedures.
  9. Assists with departmental projects and other functions as assigned to support department operations and/or assist with patient specific issues that may arise.
  10. Provides functional assistance to include:
  11. Working with case managers, social workers, management teams and other groups as necessary to identify and manage utilization issues that impact hospital revenues.
  12. Working collaboratively with Director of Appeals/UM, Social Work and Director of CRM to problem solve core issues which may cause delays in hospital reimbursement.
  13. Making follow-up calls.
  14. Preparing written appeals to facilitate the denials process.
    1. Escalates issues to utilization leadership as required.
    2. Participates in committees as required.
    3. Performs other related duties as assigned.



EDUCATION  Bachelor of  Science in Nursing is required.  Familiarity using a personal computer including word processing and spreadsheets is required.  Knowledge of reimbursement models (commercial, managed care, Medicare) is preferred.

PRIOR EXPERIENCE  Three to five years experience as a clinical nurse in an acute care setting. Prior experience in a hospital or office type setting preferred, prior experience as a Case Manager.  Knowledge of MS Office Suite required. Insurance/payer experience preferred/prior utilization review experience preferred.  Proficiency in Allscripts, MCG and InterQual preferred.

ON THE JOB EXPERIENCE Approximately six months to gain familiarity with the hospital environment, department routines and procedures and full range of duties.

PROBLEM SOLVING  Ability to establish priorities, meet deadlines and maintain standards of productivity.

INTERNAL CONTACTS  Internal contacts necessary to effectively advise, consult or counsel others to gain cooperation and acceptance of ideas or actions.

INDEPENDENT JUDGEMENT Work assignments are generally received in the form of results expected, due dates, and general approach to be taken. Ability to incorporate clinical skills, theoretic concepts and knowledge of costs in determining effective and appropriate course of action.

PATIENT CARE Assists with patient care by establishing and/or monitoring the techniques, policies, and procedures used by those who deliver care; and by assisting in the coordination of patient care planning and discharge plans.

RESPONSIBILITY FOR WORK OF OTHERS  Not responsible for supervising others.

CERTIFICATION/REGISTRATION/LICENSURE  Licensure as a registered nurse in the District of Columbia is required.


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