Utilization Management Nurse

Essential Job Duties

• 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

Educational/Experience Requirements

• Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience
• Three years of clinical nursing in an acute care hospital setting

Required License/Certifications

• Current RN license from Maryland Board of Nursing

Working Conditions, Equipment, Physical Demands

• The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position.

Pay Range

• $34—$55 USD

Luminis Health Benefits Overview

• 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
• Benefits Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more
• Benefit offerings based on employment status