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Medical Review Rn Jobs in Washington (NOW HIRING)

MedStar Health

RN Utilization Mgmt

Washington, DC · On-site

$89.07K - $162.80K/yr

Sends thorough reviews to Medical Director as appropriate. Coordinates timely review decisions and ... Valid RN license in the District of Columbia; or Maryland required and * Bachelor's degree ...

Virginia Heart

Registered Nurse (RN)

Falls Church, VA

$34 - $38.50/hr

... reviewing current medications and allergies, updating patient history and review of systems ... Computer literate and prior experience with an Electronic Medical Record (EMR), EPIC preferred.

Virginia Heart

Registered Nurse (RN)

Vienna, VA

$34 - $38.50/hr

... reviewing current medications and allergies, updating patient history and review of systems ... Computer literate and prior experience with an Electronic Medical Record (EMR), EPIC preferred.

Virginia Heart

Registered Nurse (RN)

Fairfax, VA

$34 - $38.50/hr

... reviewing current medications and allergies, updating patient history and review of systems ... Computer literate and prior experience with an Electronic Medical Record (EMR), EPIC preferred.

Virginia Heart

Registered Nurse (RN)

Alexandria, VA

$34 - $38.50/hr

... reviewing current medications and allergies, updating patient history and review of systems ... Computer literate and prior experience with an Electronic Medical Record (EMR), EPIC preferred.

Virginia Heart

Registered Nurse (RN)

Arlington, VA

$34 - $38.50/hr

... reviewing current medications and allergies, updating patient history and review of systems ... Computer literate and prior experience with an Electronic Medical Record (EMR), EPIC preferred.

Virginia Heart

Registered Nurse (RN)

Dulles, VA

$34 - $38.50/hr

... reviewing current medications and allergies, updating patient history and review of systems ... Computer literate and prior experience with an Electronic Medical Record (EMR), EPIC preferred.

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What are the key skills and qualifications needed to thrive as a Medical Review RN, and why are they important?

To thrive as a Medical Review RN, you need a strong clinical background, critical thinking skills, and an active RN license, often supported by experience in case management or utilization review. Familiarity with medical coding, claims management software, and knowledge of regulatory guidelines such as Medicare and Medicaid are typically required. Strong attention to detail, excellent written communication, and the ability to work independently are essential soft skills for this role. These competencies ensure accurate and compliant medical record reviews, which are critical for proper claims adjudication and regulatory adherence.

How does a Medical Review RN collaborate with other healthcare professionals during the review process?

A Medical Review RN often works closely with physicians, case managers, and insurance representatives to ensure that medical claims and treatment plans meet regulatory and clinical guidelines. Collaboration may involve participating in interdisciplinary meetings, discussing complex cases, and providing clinical expertise to support utilization management decisions. Effective communication and teamwork are essential, as you'll need to relay findings, request additional information, and sometimes clarify medical necessity with providers. This collaborative environment helps ensure quality care for patients while maintaining compliance with payer policies.

What is a Medical Review RN?

A Medical Review RN is a registered nurse who specializes in reviewing medical records and claims to ensure they meet established guidelines and standards. These nurses often work for insurance companies, government agencies, or healthcare organizations, evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. Their role may include determining medical necessity, performing utilization reviews, and supporting appeals or audits. They use their clinical knowledge to interpret complex medical information and collaborate with healthcare providers to support accurate decision-making.

How to become a medical review nurse?

To become a medical review nurse, one must typically earn a nursing license by completing an accredited nursing program and passing the NCLEX-RN exam. Experience in clinical nursing and knowledge of medical coding, documentation, and healthcare regulations are also important, and some roles may require certification in case management or utilization review.
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Infographic showing various Medical Review Rn job openings in Washington as of May 2026, with employment types broken down into 1% As Needed, 86% Full Time, 8% Part Time, and 5% Contract. Highlights an 100% Physical job distribution.
RN Utilization Mgmt

RN Utilization Mgmt

MedStar Health

Washington, DC • On-site

$89.07K - $162.80K/yr

Full-time

Posted 9 days ago

Medstar Health rating

7.7

Company rating: 7.7 out of 10

Based on 237 frontline employees who took The Breakroom Quiz

158th of 864 rated healthcare providers

Job description

About the Job
General Summary of Position
The RN Utilization Manager will have 1-2 years of Utilization review- responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities. Responsible for clinical review of acute care services based on Medically Necessity criteria the management of quality health care resources for achievement of desired outcomes and coordination of alternative levels of care in a timely and in the most cost-effective manner.We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels.
Primary Duties and Responsibilities
  • Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
  • Acts as a liaison to MedStar Family Choice (MFC) contracted vendors to facilitate care. Identifies gaps in contracted services and develops a plan to access care.
  • Acts as an advocate while assisting members 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.
  • Attends and participates in MFC staff meetings Clinical Operations department meetings Special Needs Forums work groups etc. as assigned. Provides input completes assignments and shares new findings with other staff. Participates in meetings and on committees and represents the department and MFC in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.
  • Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
  • Demonstrates skill and flexibility in providing coverage for other staff.
  • Identifies inpatients requiring additional services and initiates care with appropriate providers. Demonstrates emphasis on quality patient care during the pre-admission and/or concurrent review process. Authorizes services according to MedStar Family Choice policy.
  • Initiates contact with providers to obtain clinical information to facilitate approval or pending of pre-authorization requests inpatient stays and retrospective reviews.
  • Maintains current knowledge of MFC benefits and enrollment issues in order to accurately coordinate services.
  • Maintains timely and accurate documentation in the clinical software system per Clinical Operations department's policy.
  • Monitors utilization of all services for fraud and abuse.
  • Performs pre-authorization and pharmacy reviews and documents in PBM's system when assigned.
  • Performs telephonic ACD line coverage for Clinical Operations' needs.
  • Performs telephonic inpatient utilization review services; on-site review as indicated. Process includes: assessment planning coordinating and implementation. Monitors for timely provision of services. Assists hospital case management staff with discharge planning as applicable.
  • Makes referrals to Case Management as needed.
  • Sends thorough reviews to Medical Director as appropriate. Coordinates timely review decisions and notifications per policy NCQA standards/guidelines and District of Columbia Contract.
  • Utilizes evidence-based standards in making coverage determinations in individual patient cases; Identifies and reports potential coordination of benefits subrogation third party liability worker's compensation cases etc. Identifies quality risk or utilization issues to appropriate MedStar personnel.

Minimal Qualifications
Education
  • Valid RN license in the District of Columbia; or Maryland required and
  • Bachelor's degree preferred

Experience
  • 1-2 years Recent utilization experience required and
  • 1-2 years Diverse clinical experience required

Licenses and Certifications
  • RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia; or Maryland Upon Hire required and
  • CCM - Certified Case Manager CCM (Certified Case Manager) Upon Hire preferred

Knowledge Skills and Abilities
  • Proficient computer skills to enter and retrieve data.
  • Ability to create edit and analyze Microsoft office (Word Excel and PowerPoint) preferred.
  • Knowledge of InterQual guidelines preferred.

This position has a hiring range of
USD $89,065.00 - USD $162,801.00 /Yr.

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About Medstar Health

Sourced by ZipRecruiter

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Columbia, MD, US

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