Utilization Management RN

Job Title
Utilization Management RN
Job ID
27746385
Work Hybrid
Yes
Location
Washington, DC, 20008  Hybrid
Other Location
Description
V-Tech Solutions, Inc. is looking for a Case Management Utilization Review Nurse to support our client. The successful candidate will provide expert clinical assessments and utilization reviews to ensure the most efficient and cost-effective care for our patients. Collaborating with interdisciplinary teams, the case management utilization review nurse will address psychiatric, psychosocial needs, ensuring member satisfaction and adherence to standards.
*4 days per week on-site in DC and 1 day remote*

​​​​​​​​​​​​Key Responsibilities
  • Conduct clinical assessments and utilization reviews to evaluate the appropriateness of admissions, continued stays, and discharge plans based on established guidelines.
  • Actively develops and manages complex case management cases and develops individualized plans of care according to NCQA standards/ guidelines and the District of Columbia Contract.
  • Acts as an advocate while assisting members/enrollees to coordinate and gain access to medical, psychiatric, psychosocial and other essential services to meet their healthcare needs. Authorizes and monitors covered services according to policy.
  • Apply evidence-based criteria (e.g., InterQual, Milliman) to ensure optimal resource utilization and quality outcomes.
  • Collaborate with multidisciplinary teams, including physicians, social workers, and other healthcare professionals, to develop and coordinate patient care plans.
  • Communicate with insurance companies, payers, and third-party entities to obtain authorization for services and ensure timely reimbursement.
  • Identify and address barriers to care and recommend alternative care options when necessary.
  • Provide education to patients and families regarding discharge planning, community resources, and post-acute care needs.
  • Maintain accurate, detailed, and timely documentation of all case management and utilization review activities in compliance with regulatory and organizational standards.
  • Monitor and track patient outcomes, ensuring adherence to established benchmarks and quality metrics.
  • Participate in quality improvement initiatives, audits, and performance reviews related to case management and utilization review processes.
Qualifications
    • ADN, BSN, MSN, or CNL from an accredited School of Nursing required.
    • 3-4 years Case Management experience required, 3-4 years Utilization Management or related experience required, 5-7 years diverse clinical experience required, and 3-4 years acute inpatient care clinical experience required.
    • Active DC RN License and Basic Life Support for Healthcare providers required
Pay Range
$93,000.00   Annually to $104,000.00   Annually