Clinical Utilization Review Specialist

University of Maryland Medical System Corporation; Largo (MD); On-site; USD 56,000 - 84,000; Full time

Job summary

University of Maryland Capital Region Medical Center, Largo, MD, seeks an experienced utilization review professional to manage denials and assess the appropriate level of care using nationally recognized guidelines. You will interface with case managers, medical teams, and payers to optimize patient care and reimbursement.

Requirements include a BSN, current Maryland RN license, and BLS. CPUR is preferred, with prior UMMS experience and knowledge of utilization management software.

Qualifications

• Bachelor of Science in Nursing is required; Master’s degree preferred.
• Maryland RN license active with the Maryland Board of Nursing.
• Current BLS–Health Care Provider cert.
• Certified Professional Utilization Reviewer (CPUR) preferred.

Responsibilities

• Performs timely and accurate utilization review for all patient populations.
• Communicates with clinical care teams and payors regarding reviews and denials.
• Supports concurrent appeals process with 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.
• Reviews tests, procedures and consultations for resource utilization.
• Conducts HINN discussions and Observation Education.
• Collaborates with care coordinators on Avoidable Days collection.
• Ensures regulatory compliance related to utilization management.
• Pursues opportunities to improve reimbursement.

Skills

Verbal communication

Written communication

Analytical skills

Team building

Prioritization

Independent work

Collaboration

Utilization management software

Microsoft Word

Medical terminology

Education

Bachelor of Science in Nursing

Master of Nursing (preferred)

Maryland RN license

BLS – Healthcare Provider

Tools

Microsoft Word

Utilization Management software (UM)

Job description

University of Maryland Capital Region Medical Center, Largo, MD, seeks an experienced utilization review professional to manage denials and assess the appropriate level of care using nationally recognized guidelines. You will interface with case managers, medical teams, and payers to optimize patient care and reimbursement.

Requirements include a BSN, current Maryland RN license, and BLS. CPUR is preferred, with prior UMMS experience and knowledge of utilization management software.