Utilization Management Nurse - Surgical Services POE

Luminis Health, Inc.; Lanham (MD); On-site; USD 34,000 - 55,000; Full time

Job summary

Luminis Health is seeking a Registered Nurse to perform concurrent and retrospective chart reviews to assess clinical, financial, and resource utilization and to coordinate care. The role includes intervention to reduce delays and denials, working with care coordinators and physicians to resolve payer issues, and participating in process-improvement initiatives.

Requirements include a BSN (or ADN with equivalent experience) and at least three years of acute care nursing, with an active Maryland

Qualifications

• RN license required (Maryland Board of Nursing)
• BSN must be achieved within 5 years of start date
• Three years of clinical nursing in an acute care hospital setting

Responsibilities

• Conduites concurrent and retrospective chart review to assess clinical, financial, and resource utilization.
• Monitor denial patterns and collaborate with care coordinators to resolve and prevent denials.
• Collaborate with care coordinators to achieve optimal patient outcomes, shorten length of stay, and expedite appeals when needed.
• Participate in nursing unit and department clinical outcome projects and care management process improvements.

Skills

Chart review

Denial management

Care coordination

Process improvement

Education

Bachelor of Science in Nursing

Associate degree in Nursing

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

• 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.

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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