Utilization Management Spec

The University Of Maryland Medical System Baltimore , MD 21203

Posted 1 week ago

Job ID: 66105

Area of Interest: Nursing

Location: Baltimore, MD US

Hours of Work: M-F 8a-4:30p

Job Facility: University of Maryland Medical Center

Employment Type: Not Indicated

Shift: ROTATING

What You Will Do:

  • 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.

  • 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

  • HINN discussions/Observation Education

  • Assists Case Manager in Avoidable Days Collection

  • Ownership of Regulatory Compliance related to Utilization Management conditions of participation

  • Assures appropriate reimbursement and stewardship of organizational and patient resources.

  • Actively reports opportunities to improve reimbursement and responds to relevant data

  • Collaborates with admitting specialists regarding authorization policies and procedures of third party payers.

  • Remains current on clinical practice and protocols impacting clinical reimbursement

What You Need to Be Successful:

Education and Experience

  • Bachelors in Nursing required. Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is preferred.

  • One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred. Two years experience in acute care and four years clinical healthcare experience preferred. Certified Professional Utilization Reviewer (CPUR) preferred. Additional experience in home health, ambulatory care, and/or occupational health is preferred.

We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.


icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Utilization Management Operations Lead St Agnes

R1 Revenue Cycle Management

Posted 6 days ago

VIEW JOBS 3/19/2019 12:00:00 AM 2019-06-17T00:00 R1 RCM Inc. is a leading provider of technology-enabled revenue cycle management services which transform and solve challenges across health systems, hospitals and physician practices. Headquartered in Chicago, R1® is a publicly-traded organization with employees throughout the US and international locations. Our mission is to be the one trusted partner to manage revenue, so providers and patients can focus on what matters most. Our priority is to always do what is best for our clients, patients and each other. With our proven and scalable operating model, we complement a healthcare organization's infrastructure, quickly driving sustainable improvements to net patient revenue and cash flows while reducing operating costs and enhancing the patient experience. The Utilization Management Operations Lead will be responsible for partnering with client representatives and the R1® team to perform detailed reviews of facility-wide financial and operational metrics with the goal of identifying and capitalizing upon opportunities for process, cost, and patient satisfaction improvement. In this role, the successful candidate will collaborate with client representatives and the R1® team to identify, review, and monitor key indicators for potential process improvement opportunities. The successful candidate must have critical thinking skills and have demonstrated competency analyzing data and completing process improvement initiatives. Responsibilities: * Maintain a strong focus on identifying the root cause of denials while creating sustainable solutions to prevent future denials. * Utilize R1®technology, training, and process excellence initiatives across all aspects of revenue cycle. * Interpret data sets and create data analyses to drive desired results. * Respond to ad-hoc requests and develop solutions in a timely manner. * Coach all staff to improve workflow and operational performance. * Provide value-add feedback to R1® leadership on development of project plans. * Ensures the execution and compliance of the denials playbook. * Other activities as determined by the Site Lead. * Review concurrent, initial, and final denials for root cause and identify opportunity for upstream process improvement * Create in-process tracking and trending to allow for early identification of defects * Collaborate with hospital clinical departments, Case Management, Patient Access, Coding, Billing, Physician Advisors, Managed Care, etc. to implement practices to prevent future denials * Escalate wrongful denials to payer meetings for resolution Required Qualifications: * A Bachelor's degree and demonstrated academic achievement. * 2-5 Years professional experience demonstrating progressive responsibility. * Critical thinking skills – The ability to analyze, communicate, and creatively problem solve with an open mind. * Interpersonal Skills – The ability to establish oneself as a peer and trusted partner for our client counterparts. * Change Management – The ability to help counterparts through difficult transitions to a new process, workflow, or situation. * Motivation / Drive – Successful candidates will have a desire for continuous learning. Self-starting and going beyond what is asked to take on new challenges and create innovative solutions. * Tenacity /Grit – This role will require getting deep into details and performing very granular reviews and extensive process shadowing. While this work can be tedious, it is foundational to success. Desired Qualifications: * Direct experience in denials reduction initiatives, including familiarity with insurance portals * Professional experience with Utilization Management best practices. * Working knowledge of Utilization Review evidence-based criteria and care guidelines, including InterQual®, MCG® and the Two-Midnight Rule. Working in an evolving healthcare setting, we use our shared expertise to deliver innovative solutions. Our fast-growing team has opportunities to learn and grow through rewarding interactions, collaboration and the freedom to explore professional interests. Our associates are given valuable opportunities to contribute, to innovative and create meaningful work that makes an impact in the communities we serve around the world. We also offer a culture of excellence that drives customer success and improves patient care. We believe in giving back to the community and offer a competitive benefits package. To learn more, visit: r1rcm.com R1 Revenue Cycle Management Baltimore MD

Utilization Management Spec

The University Of Maryland Medical System