Travel Nurse (RN) - Utilization Review

Pre-employment modules may be required for this role. Please upload any certifications or health documents you have to your profile to expedite your on-boarding process.

Additional Details:

References must cover at least 1 full year of relevant experience in specialty within the past 3 years.

Manager may or may not interview. Clinician must be okay with this. If Clinician has questions, please email the AM.

Hybrid position 2 days a week in the office, and the other days are remote. Initial set up and training will require at least daily in the office for 1-2 weeks.

Skills Req: Insurance Company, Care Coordination, Concurrent Review, Continue stay reviews, Determine Medical Necessity per Evidence-Based Guidelines Review, Discharge Planning, Pre-Cert Review, Prior Authorizations, Utilize InterQual Criteria, Admission Criteria and Concurrent stay Review

Preferably experienced in doing pre-authorizations for a health plan. Previous Charge Experience Preferred

Regulatory Skills Req: CMS: Centers for Medicare and Medicaid Services, CPT (Current Procedural Terminology) coding and billing, Department of Health, DRG (Diagnosis Related Groups), HEDIS (The Healthcare Effectiveness Data and Information Set) Measures, HIPAA (The Health Insurance Portability and Accountability Act), ICD 10 Coding, NCQA (National Committee for Quality Assurance), OSHA: Occupational Safety and Health Administration The Joint Commission/ Core Measure/National Safety Goals, Worker’s Compensation

Chronic diagnoses (High Risk Pregnancy, Postpartum, DM, CHF, COPD, Asthma, obesity/overweight, All Behavorial Health, etc.)

Will need to make calls to enrollees in Washington DC area to complete comprehensive assessments, developing care plans, and ongoing management within the EMR (guiding care/Healthedge).

Care plans must be individualized and address Social Determinants of Health (sDOH) needs. Must be able to collaborate with hospitals, physicians, etc. to ensure successful execution of the care plan.

Documentation must reflect NCQA and contract requirements / timelines.

Enrollees are Medicaid recipients, the most vulnerable population. Must be able and willing to care for Pregnant Persons/Newborns to Geriatric age groups.

RTO - RTO must be on the submittal and cannot be changed once the profile has been sent to the manager for review. Please ensure all RTO is for the full 13 weeks for each submittal Amount of RTO: Please, no more than 7 days of RTO per 13 week contract - highly preferred. No RTO the first two weeks of an assignment.

Return Staff Policy If a nurse has held previous employment with Medstar, must be gone for a minimum of 1 year to return as a traveler.