Utilization Management Specialist

What You Will Do:

Main Function:

Under general supervision, provides utilization review and denials management for an assigned patient case load. This role utilizes nationally recognized care guidelines/criteria to assess the patient’s need for outpatient or inpatient care as well as the appropriate level of care. The role requires interfacing with the case managers, medical team, other hospital staff, physician advisors and payers.

Duties and Responsibilities:

• Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
• Communicates with case manager, physician advisor, medical team 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.
• HINN discussions/Observation Education.
• Assists Case Manager in Avoidable Days Collection.
• Ownership of Regulatory Compliance related to Utilization Management conditions of participation.
• Assures appropriate reimbursement and stewardship of organizational and patient resources.
• Actively reports opportunities to improve reimbursement and responds to relevant data.

What You Need to Be Successful:

Education:

• Bachelor’s in Nursing or active pursuit of BSN required. Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is preferred.
• 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.

We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.