Case Manager/ Utilization Reviewer
Job Requirements
Located in Largo in the heart of Prince Georges County, our new state-of-the-art regional medical center (University of Maryland Capital Region Medical Center) will provide improved access to primary and ambulatory care services and serve as a tertiary care center for critically ill patients. In addition, our new space will allow us to expand our offerings as a community partner to help improve the health status of Prince Georges County residents.
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 patients 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.
1. Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer. 2. Communicates with clinical care coordinators, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions. 3. Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation. 4. Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg). 5. Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner. 6. Conducts HINN discussions/Observation Education. 7. Collaborates with Clinical Care Coordinators concerning Avoidable Days Collection. 8. Ensures Regulatory Compliance related to Utilization Management conditions of participation. 9. Assures appropriate reimbursement and stewardship of organizational and patient resources. 10. Pursues and reports opportunities to improve reimbursement. 11. Remains current on clinical practice and protocols impacting clinical reimbursement.
Work Experience
Licensure Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required Education Bachelors in Nursing required. Experience One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred. Two years experience in acute care and four years clinical healthcare experience preferred. Certified Professional Utilization Reviewer (CPUR) preferred. Additional experience in home health, ambulatory care, and/or occupational health is preferred
Benefits
Benefits All your information will be kept confidential according to EEO guidelines. Compensation: Pay Range:$40.61-$60.96 Other Compensation (if applicable):
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