Clinical Utilization & Care Optimization Specialist

University of Maryland Medical System Corporation; Baltimore (MD); On-site; USD 85,000 - 110,000; Full time

Job summary

University of Maryland Medical System Corporation is seeking a Nursing professional to perform utilization review and denials management for an assigned patient load. You will apply nationally recognized guidelines to assess outpatient or inpatient care and coordinate with case managers, physicians, and payers to optimize care and reimbursement.

Responsibilities include managing reviews, supporting concurrent appeals, and ensuring proper level of care across observation, inpatient, and other

Qualifications

• BSN or active pursuit required; RN license in Maryland preferred.
• Experience in case management or utilization management desired.
• CPUR certification preferred; other related health care experience advantageous.

Responsibilities

• Performs timely and accurate utilization review for patient populations.
• Communicates with case managers, physicians, and payers regarding reviews and denials.
• Supports concurrent appeals with proactive referrals and documentation.
• Ensures appropriate level of care and patient status across care settings.
• Reviews tests and procedures for appropriate resource utilization.

Skills

Utilization management

Verbal communication

Written communication

Analytical skills

Team collaboration

Physician collaboration

Education

Bachelor’s in Nursing (BSN)

Maryland RN licensure

CPUR preferred

Compact state eligibility

Tools

Utilization management software

Job description

University of Maryland Medical System Corporation is seeking a Nursing professional to perform utilization review and denials management for an assigned patient load. You will apply nationally recognized guidelines to assess outpatient or inpatient care and coordinate with case managers, physicians, and payers to optimize care and reimbursement.

Responsibilities include managing reviews, supporting concurrent appeals, and ensuring proper level of care across observation, inpatient, and other