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  • Utilization Management Nurse - Annapolis - Luminis Health

    Luminis Health
    Luminis Health Annapolis

    1 week ago

    Default job background
    Description

    Utilization Management Nurse - Emergency Department

    This is an onsite role at Anne Arundel Medical Center in Annapolis, MD.

    Job Summary:

    We are seeking a skilled Utilization Management Nurse to conduct concurrent and retrospective chart review for clinical, financial, and resource utilization information. The successful candidate will provide intervention and coordination to decrease avoidable delays and denial of payment.

    Essential Job Duties:

    1. Chart Review:

    The nurse will review the medical record by applying utilization review criteria to assess clinical, financial, and resource utilization. This includes entering clinical review in EPIC, maintaining close communication with external reviews, care coordinators, and providers, and reconciling and recording days authorized in EPIC.

  • Denial Management:
  • The nurse will monitor and identify patterns or trends in utilization management, monitor potential and actual denials, and collaborate with care coordinators for any follow-up necessary. They will also document actions taken to avoid denial and assist Care Coordinators in communicating with patients denied hospital days to work toward resolution and discharge.

  • Care Coordination:
  • The nurse will collaborate with Care Coordinators to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays, and denied days. They will utilize Physician Advisors and administrative personnel for unresolved issues, identify opportunities for expedited appeals, and collaborate with Care Coordinators and Physician Advisors to resolve payer issues.

  • Process Improvement Initiatives:
  • The nurse will participate in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.

    Requirements:

    • Bachelor's of Science in Nursing or Associate's degree in Nursing with equivalent experience. BSN must be achieved within 5 years of start date in the role.
    • Three years of clinical nursing in an acute care hospital setting.

    License/Certifications:

    • Current RN license from Maryland Board of Nursing.

    Working Conditions:

    There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.


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