Utilization Management Nurse - Denials
Luminis Health Inc, Annapolis, MD, United States
Position Objective
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.
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. BSN must be achieved within 5 years of start date in the role.
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
There is a reasonable expectation that employees in this position will be exposed to blood‑borne pathogens.
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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.
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
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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.
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. BSN must be achieved within 5 years of start date in the role.
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
There is a reasonable expectation that employees in this position will be exposed to blood‑borne pathogens.
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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.
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
#J-18808-Ljbffr