Utilization Reviewer

Position Summary

Located in Largo, Prince George’s County, our state-of-the-art regional medical center will provide improved access to primary and ambulatory care services and serve as a tertiary care center for critically ill patients. This role will assess patient needs and appropriate levels of care, interfacing with various hospital staff and payers.

Primary Responsibilities

• Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
• Communicates with clinical care coordinators, physician advisors, and payors as needed regarding reviews and pended/denied days and interventions.
• Supports concurrent appeals process through proactive identification of pended/denied days.
• Implements the concurrent appeals process with appropriate referrals and documentation.
• Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg).
• Reviews tests, procedures, and consultations for appropriate utilization of resources in a timely manner.
• Conducts HINN discussions/Observation Education.
• Collaborates with Clinical Care Coordinators concerning Avoidable Days Collection.
• Ensures Regulatory Compliance related to Utilization Management conditions of participation.
• Affirms appropriate reimbursement and stewardship of organizational and patient resources.
• Pursues and reports opportunities to improve reimbursement.
• Collaborates with admitting specialists regarding authorization policies and procedures of third-party payers.
• Remains current on clinical practice and protocols impacting clinical reimbursement.

Work Experience and Education

• Bachelor's in Nursing required.
• Licensure as a Registered Nurse in the state of Maryland, or eligibility due to Compact state agreements, is required.
• One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred.
• Two years' experience in acute care and four years clinical healthcare experience preferred.
• Certified Professional Utilization Reviewer (CPUR) preferred.
• Additional experience in home health, ambulatory care, and/or occupational health is preferred.

Knowledge, Skills and Abilities

• Highly effective verbal and written skills are required.
• Strong communication skills, self-confidence, and experience in working with physicians are required.
• Excellent analytical and team building skills, as well as the ability to prioritize and work independently are required.
• The ability to work collaboratively with other disciplines is required.
• The ability to work with Hospital/Utilization Management and related software programs is required.
• Knowledge of utilization management is preferred.