Utilization Management Denials Nurse

Socket.dev; Annapolis (MD); On-site; USD 47,000 - 76,000; Full time

Benefits offered by this job

Medical Insurance

Retirement Plan

Paid Time Off

Job summary

Luminis Health in Annapolis, MD is seeking a Registered Nurse to conduct concurrent and retrospective chart reviews to support clinical, financial, and resource utilization decisions. The role focuses on reducing delays, denials, and length of stay through effective coordination with the care team.

Responsibilities include utilization review, denial management, and participation in process improvement initiatives to optimize patient outcomes and hospital efficiency.

Qualifications

• Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience.
• BSN must be achieved within 5 years of start date in the role.
• Three years of clinical nursing in an acute care hospital setting.

Responsibilities

• Chart Review: Review medical records to assess clinical, financial, and resource utilization; enter in EPIC and communicate with external reviews and providers.
• Denial Management: Monitor denials and work with care coordinator to resolve payer issues and avoid denial.
• Care Coordination: Collaborate to improve patient outcomes, reduce length of stay and delays, and expedite appeals.
• Process improvement initiatives: Participate in nursing unit and department clinical outcome projects.

Skills

Clinical nursing

Utilization review

Care coordination

Communication

Education

BSN or ADN

Tools

EPIC

Job description

Position Objective

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 Job Duties

1. Chart Review:

   Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC.

2. Denial Management:

   Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge.

3. Care Coordination:

   Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues.

4. Process improvement initiatives:

   Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.

Educational/Experience Requirements

• Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience. BSN must be achieved within 5 years of start date in the role.
• Three years of clinical nursing in an acute care hospital setting.

Required License/Certifications

• Current RN license from Maryland Board of Nursing.

Working Conditions, Equipment, Physical Demands

There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.

Physical Demands

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

Pay Range

$34—$55 USD

Luminis Health Benefits Overview

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs and more
• *Benefit offerings based on employment status

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