Utilization Management Denials Nurse

Luminis Health, Inc.; Annapolis (MD); On-site; USD 47,000 - 76,000; Full time

Job summary

Luminis Health seeks a registered nurse to conduct concurrent and retrospective chart review, focusing on clinical, financial, and resource utilization information to support timely and appropriate patient care.

The role involves denial management, close collaboration with care coordinators, and participation in process improvement initiatives within care management to reduce length of stay and avoid delays.

Qualifications

• Bachelor's of Science in Nursing or Associate's degree in Nursing; BSN must be achieved within 5 years.
• Three years of clinical nursing in an acute care hospital setting.

Responsibilities

• Reviews medical records to assess clinical, financial, and resource utilization.
• Monitors denial patterns and collaborates with care teams to avoid denial.
• Collaborates with Care Coordinator to reduce length of stay and delays.
• Participates in process improvement initiatives within care management.

Skills

Clinical nursing

RN license

Education

BSN or ADN with equivalent experience

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

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

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.

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.

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.

RequiredLicense/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