Utilization Review Nurse RN - Grace Medical Center
Lifebridge Health, Inc., Baltimore, MD, United States
Facility GRACE MEDICAL CENTER
Responsibilities
Conduct initial, concurrent and retrospective chart review for clinical, financial and resource utilization information. Provide intervention and coordination to decrease avoidable delays and denial of payment. Interface with third‑party payers by providing pertinent, relevant clinical information.
Review the medical record by applying utilization review criteria to assess clinical, financial, and resource consumption. Enter clinical reviews into the software program. Maintain close communication with external reviewers, internal financial counselors, patient access personnel and perform certification activities as required by payor.
Monitor and identify patterns or trends in utilization management. Monitor potential and actual denials and coordinate with nurse care manager and/or social worker for follow‑up. Document in the software program the actions taken to coordinate care and avoid denials. Assist nurse care managers in communicating with patients denied hospital days and in the issuance of Medicare forms such as HINN, Detailed Notice of Discharge to patients/family/significant others when they disagree with the discharge plan arranged by attending and care‑management personnel.
Coordinate with the care manager to achieve optimal and efficient patient outcomes while decreasing length of stay and avoiding delays or denied days. Utilize physician advisor and administrative personnel for unresolved issues. Identify opportunities for expedited appeals and collaborate with the care manager and physician advisor to resolve payer issues. Perform other tasks as assigned.
Send appropriate referrals or escalations to the physician advisors when a case does not meet criteria.
Requirements
Current RN license in MD (or Compact State as applicable).
Associate's Degree in Nursing required; BSN or higher preferred.
Minimum of 3 years of experience; 5+ years of experience preferred.
LifeBridge Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression.
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Responsibilities
Conduct initial, concurrent and retrospective chart review for clinical, financial and resource utilization information. Provide intervention and coordination to decrease avoidable delays and denial of payment. Interface with third‑party payers by providing pertinent, relevant clinical information.
Review the medical record by applying utilization review criteria to assess clinical, financial, and resource consumption. Enter clinical reviews into the software program. Maintain close communication with external reviewers, internal financial counselors, patient access personnel and perform certification activities as required by payor.
Monitor and identify patterns or trends in utilization management. Monitor potential and actual denials and coordinate with nurse care manager and/or social worker for follow‑up. Document in the software program the actions taken to coordinate care and avoid denials. Assist nurse care managers in communicating with patients denied hospital days and in the issuance of Medicare forms such as HINN, Detailed Notice of Discharge to patients/family/significant others when they disagree with the discharge plan arranged by attending and care‑management personnel.
Coordinate with the care manager to achieve optimal and efficient patient outcomes while decreasing length of stay and avoiding delays or denied days. Utilize physician advisor and administrative personnel for unresolved issues. Identify opportunities for expedited appeals and collaborate with the care manager and physician advisor to resolve payer issues. Perform other tasks as assigned.
Send appropriate referrals or escalations to the physician advisors when a case does not meet criteria.
Requirements
Current RN license in MD (or Compact State as applicable).
Associate's Degree in Nursing required; BSN or higher preferred.
Minimum of 3 years of experience; 5+ years of experience preferred.
LifeBridge Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression.
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