Utilization Management Denials Nurse

About the role

Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment.

Responsibilities

• Chart Review: Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC
• Denial Management: Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge.
• Care Coordination: Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues.
• Process improvement initiatives: Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.

Requirements

• Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience. BSN must be achieved within 5 years of start date in the role.
• Three years of clinical nursing in an acute care hospital setting.
• Current RN license from Maryland Board of Nursing.
• Working Conditions: Reasonable expectation of exposure to blood-borne pathogens; physical demands as described; reasonable accommodations may be made per ADA.

Pay

Pay Range $34—$55 USD

Benefits

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more