Utilization Review Nurse RN

Summary


The Utilization Review Nurse RN conducts initial, concurrent and retrospective chart review for clinical, financial and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment. Interfaces with 3rd party payers by providing pertinent, relevant clinical information.


Responsibilities Include:


Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource consumption. Enters clinical reviews into the software program. Maintains close communication with external reviewers/internal financial counselors/patient access personnel and performs certification activities as required by payor.


Monitors and identifies patterns or trends in utilization management. Monitors potential and actual denials and coordinates with nurse Care Manager and/or Social Worker for any follow up necessary. Documents in software program the actions taken to coordinate care and avoid denials. Assists nurse Care Managers in communicating with the patient denied hospital days as well as the issuance of Medicare forms including HINN, Detailed Notice of Discharge to patients/family/significant other when they are in disagreement with the discharge plan arranged by attending and Care Management personnel.


Coordinates with the Care Manager to achieve optimal and efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. Utilizes Physician Advisor and administrative personnel for unresolved issues. Identifies opportunities for expedited appeals and collaborates with the Care Manager and Physician Advisor to resolve payer issues. Other tasks as assigned.


Sends appropriate referrals/escalations to the physician advisors to review cases not met with criteria

REQUIREMENTS:

• Registered Nurse License - Current Maryland license or eligibility to obtain Maryland license
• Associate's Degree in Nursing required; BSN or higher preferred
• Minimum of 3 years of related experience

Additional Information

Who We Are:


LifeBridge Health is a dynamic, purpose-driven health system redefining care delivery across the mid-Atlantic and beyond, anchored by our mission to "improve the health of people in the communities we serve." Join us to advance health access, elevate patient experiences, and contribute to a system that values bold ideas and community-centered care.



What We Offer:


Impact: Join a team that values innovation and outcomes, delivering life-saving care to our youngest and most vulnerable patients.


Growth : Opportunities for professional development, including tuition reimbursement and developing foundational skills for neonatal critical care leadership and advanced certification.


Support: A culture of collaboration with resources like unit-based practice councils and advanced clinical education support - improving both workflow efficiency and patient outcomes and allowing you to work at the top of your license.


Benefits : Competitive compensation (additional compensation such as overtime, shift differentials, premium pay, and bonuses may apply depending on job), comprehensive health plans, free parking, and wellness programs.



Why LifeBridge Health?


With over 14,000 employees, 130 care locations, and two million annual patient encounters, we combine strategic growth, innovation, and deep community commitment to deliver exceptional care anchored by five leading centers in the Baltimore region: Sinai Hospital of Baltimore, Grace Medical Center, Northwest Hospital, Carroll Hospital, and Levindale Hebrew Geriatric Center and Hospital.


Our organization thrives on a culture of CARE BRAVELY-where compassion, courage, and urgency drive every decision, empowering teams to shape the future of healthcare.


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 race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression.