Job Description

I. General Summary

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.

II. Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• 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 manner

Qualifications

III. Education 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

IV. Knowledge, Skills and Abilities

• Knowledge 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.

V. Patient Safety

Ensures patient safety in the performance of job functions and through participation in hospital, department or unit patient safety initiatives.

• Takes action to correct observed risks to patient safety.
• Reports adverse events and near misses to appropriate management authority.
• Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation:

Pay Range: $34.01 - $47.18

Other Compensation (if applicable):

Review the 2024-2025 UMMS Benefits Guide