Utilization Review Nurse RN - Grace Medical Center

Utilization Review Nurse RN – Grace Medical Center, Baltimore, MD Job Summary Conduct initial, concurrent, and retrospective chart review for clinical, financial, and resource utilization information. Provide intervention and coordination to decrease avoidable delays and denial of payment. Interface with third‑party payers by providing pertinent, relevant clinical information. Review medical records applying utilization review criteria to assess clinical, financial, and resource consumption. Enter clinical reviews into the software program. Maintain close communication with external reviewers, internal financial counselors, patient access personnel, and perform certification activities as required by pay‑or. Monitor and identify patterns or trends in utilization management. Monitor potential and actual denials and coordinate with nurse Care Manager and/or Social Worker for any follow‑up necessary. Document actions taken in software to coordinate care and avoid denials. Assist nurse Care Managers in communicating with patients denied hospital days and in issuing Medicare forms including HINN, Detailed Notice of Discharge to patients/family/significant others when they disagree with the discharge plan. Coordinate with Care Manager to achieve optimal and efficient patient outcomes, while decreasing length of stay and avoiding delays and denied days. Utilize Physician Advisor and administrative personnel for unresolved issues. Identify opportunities for expedited appeals and collaborate with Care Manager and Physician Advisor to resolve payer issues. Send appropriate referrals or escalations to physician advisors for cases not meeting criteria. Other tasks as assigned. Qualifications Current RN license in MD (or applicable Compact State). Associate's Degree in Nursing required; BSN or higher preferred. Minimum of 3 years of experience; 5+ years preferred. Benefits Competitive compensation with potential overtime, shift differentials, premium pay, and bonuses. Comprehensive health plans. Free parking and wellness programs. Opportunities for professional development, including tuition reimbursement and training for neonatal critical care leadership and advanced certification. Culture of collaboration with unit‑based practice councils and advanced clinical education support. Work at the top of your license within a supportive environment. Legal Notice: LifeBridge Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression. LifeBridge Health does not exclude people or treat them differently because of these characteristics. #J-18808-Ljbffr