Utilization Review Nurse RN - Grace Medical Center

Job Summary 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. Reviews the medical record 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, and patient access personnel; performs certification activities as required by payor. Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials; coordinates with nurse care manager and/or social worker for follow-up; documents actions in the software program to coordinate care and avoid denials; assists nurse care managers in communicating with patients denied hospital days and handles Medicare forms (HINN, Detailed Notice of Discharge) with patients/families who disagree with discharge plan. Coordinates with the care manager to achieve optimal and efficient patient outcomes while decreasing length of stay and avoiding delays and denied days; utilizes physician advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates to resolve payer issues; other tasks as assigned. Sends appropriate referrals or escalations to physician advisors for cases not meeting criteria. Requirements Current RN license in MD (or Compact State as applicable) Associate's Degree in Nursing required; BSN or higher preferred Minimum of 3 years of experience; 5+ years preferred Benefits Competitive compensation with possible shift differentials, bonus and overtime Comprehensive health plans Free parking Wellness programs EEO Statement 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. #J-18808-Ljbffr