Utilization Management Specialist, PRN

University of Maryland Medical System; Baltimore (MD); On-site; USD 90,000 - 120,000; Full time

Job summary

The University of Maryland Medical System is seeking a nurse with utilization review expertise to assess patient care levels and appropriate resource use. You will collaborate with case managers, physicians, and payers to optimize outcomes and maintain compliance.

Responsibilities include performing reviews, supporting the appeals process, and ensuring accurate documentation for inpatient, observation, and other care settings. Strong analytical skills and communication are essential.

Qualifications

• Knowledge of utilization management processes and guidelines.
• Excellent verbal and written communication with physicians and teams.
• Ability to analyze data and prioritize workload in a fast-paced hospital setting.

Responsibilities

• Perform timely utilization review for diverse patient populations.
• Communicate with case manager, medical team, and payers regarding reviews.
• Support concurrent appeals with referrals and documentation.
• Ensure appropriate level of care and patient status for each case.
• Stay current on clinical practices affecting reimbursement and compliance.

Skills

Utilization management knowledge

Verbal and written communication

Analytical skills

Team collaboration

Education

Registered Nurse license (Maryland)

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

Responsibilities and Tasks

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 mannerHINN discussions/Observation EducationAssists Case Manager in Avoidable Days CollectionOwnership of Regulatory Compliance related to Utilization Management conditions of participationAssures appropriate reimbursement and stewardship of organizational and patient resources.Actively reports opportunities to improve reimbursement and responds to relevant dataCollaborates with admitting specialists regarding authorization policies and procedures of third party payers.Remains current on clinical practice and protocols impacting clinical reimbursementParticipates in department improvement initiativesServes to orient and educate Utilization Manager 1sProvides oversight and education to utilization management interns placed in the practice area

Required Skills 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 Minimum of 12 months experience in case management or utilization management required Knowledge, Skills and AbilitiesKnowledge of utilization management is required. 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.