Utilization Management Nurse - Surgical Services POE

The role

This person conducts concurrent and retrospective chart reviews for clinical, financial, and resource utilization information. They provide intervention and coordination to decrease avoidable delays and denial of payment.

What you will do

• Reviews medical records by applying utilization review criteria
• Enters clinical review in EPIC
• Maintains communication with external reviews, care coordinators, and providers
• Reconciles and records days authorized in EPIC
• Monitors and identifies patterns or trends in utilization management
• Monitors potential and actual denials and collaborates with care coordinator
• Documents actions taken to avoid denial
• Assists Care Coordinator in communicating with patients denied hospital days
• Collaborates with Care Coordinator to achieve optimal patient outcomes
• Participates in nursing unit and department clinical outcome projects and process improvement initiatives

Required qualifications

• Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience
• Three years of clinical nursing in an acute care hospital setting
• Current RN license from Maryland Board of Nursing
• Exposure to blood-borne pathogens

Nice to have

• BSN must be achieved within 5 years of start date in the role

Benefits

• Medical, Dental, and Vision Insurance
• Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
• Paid Time Off
• Tuition Assistance Benefits
• Employee Referral Bonus Program
• Paid Holidays, Disability, and Life/AD&D for full-time employees
• Wellness Programs
• Employee Assistance Programs

About the company

Luminis Health.