Conduct initial, concurrent, and retrospective utilization review for hospitalized patients, focusing on chart review, medical necessity, and payer authorization issues. Support care coordination to reduce avoidable delays, denied days, and length of stay while helping resolve discharge disagreements and appeals.
Key Responsibilities
- Review medical records using utilization review criteria to assess clinical, financial, and resource utilization
- Enter clinical reviews and documentation into the designated software system
- Coordinate with care managers, social workers, patient access staff, financial counselors, and physician advisors on review and follow-up
- Monitor potential and actual denials and help identify trends in utilization management
- Assist with payer communications, certification activities, and expedited appeals
- Support communication with patients and families regarding denied hospital days and Medicare notices
- Refer cases not meeting criteria to physician advisors for review
Required
- Current Registered Nurse license in Maryland or eligibility to obtain a Maryland license
- Associate’s degree in Nursing
- At least 3 years of related experience
Preferred
- BSN or higher
Benefits & Perks
- Every Saturday and Sunday schedule
- Medical, dental, and vision coverage starting the first of the month after hire
- Wellness programs and mental health support
- 403(b) retirement plan with employer match
- Pension, life insurance, and disability insurance
- Tuition reimbursement for advanced degrees and specialty certifications
- Generous paid time off
- Fitness discounts and free on-site parking