UTILIZATION REVIEW NURSE (RN)

Position Summary: 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 Functions:

• Chart Review: Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource consumption.
• Tasks: Enters clinical reviews into the software program. Maintains close communication with external reviewers/internal financial counselors/patient access personnel and performs certification activities as required by payor.
• Denial Management: Monitors and identifies patterns or trends in utilization management
• Tasks: Monitors potential and actual denials and coordinates with nurse Care Manager and/or Social Worker for any follow up necessary. Documents in software program the actions taken to coordinate care and avoid denials. Assists nurse Care Managers in communicating with the patient denied hospital days as well as the issuance of Medicare forms including HINN, Detailed Notice of Discharge to patients/family/significant other

Qualifications/Requirements

Education/Knowledge:Basic professional knowledge; equivalent to a Bachelor's degree; working knowledge of theory and practice within a specialized field Education/Knowledge:

Education Discipline:

• Minimal degree requirement: Bachelor of Science in Nursing. (BSN's from CCNE accredited schools)

Certification or Licenses:

• Required Maryland Registered Nurse License

Experience:

• Medical terminology (Frequently)
• Nursing Process skills based on MD Nurse
• Practice Act (Frequently)
• Critical thinking skills (Frequently) Midas (Frequently)
• Healthstream (Occasionally)
• Utiization Review Criteria (Frequently)
• Microsoft Office Suite (Frequently)
• Basic computer skills (Frequently)
• Cerner (Frequently)
• Standard Office Equipment (Frequently)

Additional Comments Work from home will be 95% or greater. Training/remediation may be onsite with occasional onsite meetings.