Utilization Management Registered Nurse
Washington, District of Columbia
You'll make triage decisions on a nurse line for non-emergency transfers from local emergency services.
- Eligibility
- Case ManagementNurse TriageIntellectual and Developmental Disabilities
- Unit
- Utilization Management
Posted Jul 28
- License
- RN license Registered Nurse with multi-state license to include Washington DC, Maryland and VirginiaMulti-state RN license for DC, Maryland and Virginia
- Term
- Permanent
Do you qualify?
- License
- Multi-state RN license for DC, Maryland and Virginia Registered Nurse with multi-state license to include Washington DC, Maryland and Virginia Check your license
- Education
- ADN or BSN in nursing Associates Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN)
- Experience
- 2-5 years of case management or discharge planning 2-5 years minimum - case management or discharge planning
- Experience
- Verifiable medical utilization review experience Verifiable experience in medical utilization review
- Also asks
- Knowledge of Medicaid insurance guidelines Medicaid insurance guidelines
- Also asks
- Knowledge of healthcare systems and Medicaid programs, including work with low-income populations Knowledge of healthcare systems and Medicaid programs, including experience serving low-income populations.
- Also asks
- Strong clinical judgment and chart review skills
- Also asks
- Comfort using utilization review software and documentation systems Comfort with utilization of review software and documentation systems
- Also asks
- Excellent written and verbal communication Must have excellent written and verbal communication skills.
Preferred
- Certification
- CCM certification CCM Certification - Preferred
- Certification
- Utilization review certification or URAC-related experience or training Utilization Review Certification (URAC related experience or training) - Preferred
What it pays
- Against similar roles
- Pays above most Washington staff RN rolesWashington staff RN postings that state pay run $81k/yr to $109k/yr, the middle half $86k/yr to $91k/yr, across 71 postings.
The role and schedule
- Day to day
- Triage non-emergency calls transferred from emergency or call systems. Assess non-emergency medical needs and coordinate appropriate care routing when services are transferred from emergency or call systems
- Day to day
- Review prior authorization requests for medical necessity and choose the mode of transportation.
- Day to day
- Manage Intellectual and Developmental Disabilities requests and oversee the Level of Need process.
- Day to day
- Handle urgent authorizations and interfacility transfer requests around the clock. Maintain 24/7 availability processes for urgent transportation authorization needs, including interfacility transfer requests
- Day to day
- Issue denial determinations and explain appeal rights to beneficiaries. Provide denial determinations and communicate outcomes and appeal rights in accordance with policy requirements
- Day to day
- Help develop and run training for transportation providers and contractor staff. The position also supports the development and facilitation of education and training programs for transportation providers and contractor staff
- Details
- On-site in Washington, DC LOCATION: On-Site in the District of Columbia
The workplace
Your fit
Questions to ask
- Can you walk me through differentials?
- What should I expect for shifts, weekly hours, weekend, holiday, call, and rotation?
- What orientation, preceptor time, and ongoing unit support are included?
- How are patient load, floating, and staffing support handled day to day?
Original listing
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The multi-state Registered Nurse (RN), currently licensed and in good standing in the District of Columbia, Maryland, and Virginia, provides clinical and operational oversight for prior authorization and level-of-care determinations related to non-emergency transportation services. The RN is responsible for evaluating and investigating prior authorization requests to ensure appropriate medical necessity and determining the most suitable mode of transportation based on beneficiary needs. This role also serves as a critical clinical decision-maker for a nurse triage line, receiving transfers from local emergency services for individuals experiencing non-emergency medical conditions.
The RN assesses these cases in real time and appropriately routes beneficiaries to the nearest available non-emergency medical care setting, helping to reduce unnecessary emergency department utilization and improving care coordination. In collaboration with the Department of Disability Services and other stakeholders, the RN manages Intellectual and Developmental Disabilities (IDD) requests, oversees the Level of Need (LON) process, and ensures accurate determination of appropriate transportation resources. The position also supports the development and facilitation of education and training programs for transportation providers and contractor staff.
What's around it?
Washington, DCFrom Census ACS 2024.
Living costs about 9% above the US average
- Median rent
- $1,954/mo
- Household income
- $109,870/yr, all local households, not nurse pay