Utilization Management Coordinator

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

Job summary

The University of Maryland Medical System is seeking a utilization review professional to oversee case loads, applying nationally recognized care guidelines to determine outpatient or inpatient level of care, and coordinating with case managers, medical teams, and payers.

Under supervision, you will support deny management, documentation, and appeals, ensuring compliant utilization and appropriate reimbursement while collaborating with physicians and hospital staff.

Qualifications

• Licensure as a Registered Nurse in Maryland or eligible via compact state.
• Strong verbal and written communication skills are required.
• Experience in utilization management and working with clinicians is preferred.

Responsibilities

• Performs timely utilization review for all patient populations using care guidelines.
• Communicates with case managers, medical teams, and payers on reviews and denials.
• Supports concurrent appeals and documentation for pended/denied days.
• Ensures appropriate Level of Care and patient status for each case.
• Reviews tests and procedures for appropriate resource utilization.

Skills

Utilization management

Communication skills

Analytical skills

Team collaboration

Education

RN license (MD or compact eligibility)

Tools

EMR systems

Job description

Job Requirements

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.

Job Requirements

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.

Work Experience

The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• 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

Education And Experience

• Licensure as a Registered Nurse or other equivalent health care license in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required.

Knowledge, Skills And Abilities

• Knowledge of utilization management is preferred.
• Highly effective verbal and written skills are required.
• Strong communication skills, self-confidence and experience in working with physicians are required.
• Excellent analytical and team building skills, as well as the ability to prioritize and work independently are required.
• The ability to work collaboratively with other disciplines is required.
• Ability to work with Hospital/ Utilization Management and related software programs is required.
• 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
• Collaborates with admitting specialists regarding authorization policies and procedures of third party payers.
• Remains current on clinical practice and protocols impacting clinical reimbursement