Luminis Health

Regional health system operating three hospitals

Utilization Management Nurse - Surgical Services POE

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours

Full-time$34 - $55In-person

About the Job

Requirements

A Bachelor of Science in Nursing or an Associate’s degree in Nursing with equivalent experience is required; the BSN must be achieved within five years of starting the role.
Three years of clinical nursing experience in an acute care hospital setting are required.
A current registered nurse license from the Maryland Board of Nursing is required.
Employees are expected to be exposed to blood-borne pathogens.
The role's physical demands and work environment require performance of its essential functions, subject to reasonable accommodations under the Americans with Disabilities Act.

Responsibilities

Conduct concurrent and retrospective chart reviews for clinical, financial, and resource utilization information.
Provide interventions and coordination to decrease avoidable delays and payment denials.
Review medical records using utilization review criteria to assess clinical, financial, and resource utilization.
Enter clinical reviews in EPIC, maintain close communication with external reviewers, care coordinators, and providers, and reconcile and record authorized days in EPIC.
Monitor and identify utilization management patterns or trends, monitor potential and actual denials, and collaborate with care coordinators on necessary follow-up.
Document actions taken to avoid denials and assist care coordinators in communicating with patients whose hospital days have been denied, working toward resolution and discharge.
Collaborate with care coordinators to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays, and denied days.
Engage physician advisors and administrative personnel to resolve outstanding issues; identify opportunities for expedited appeals and collaborate with care coordinators and physician advisors to resolve payer issues.
Participate in nursing unit and department clinical outcome projects and care management process improvement initiatives.

Position Objective: Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment.

Essential Job Duties:

1. Chart Review:

Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC

2. Denial Management:

Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge.

3. Care Coordination:

Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues.

4. Process improvement initiatives

Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.

Educational/Experience 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.

RequiredLicense/Certifications:

Current RN license from Maryland Board of Nursing.

Working Conditions, Equipment, Physical Demands:

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

Physical Demands -

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.

Pay Range

$34—$55 USD

Luminis Health Benefits Overview:
• 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 and more
*Benefit offerings based on employment status

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Pay Range 34 - 55 USD

About the Company

Luminis Health

Regional health system operating three hospitals

Luminis Health operates a regional health system with three hospitals and 595 beds serving seven central Maryland counties. Care is delivered through its hospitals and affiliated centers by a large team of clinicians and staff, offering emergency services, stroke care, cancer care, and other specialties. It differentiates itself by combining two major centers into one integrated network, supported by recognitions in patient satisfaction and clinical care. Its goal is to illuminate new possibilities in health care for the community by expanding access, improving outcomes, and advancing care through collaboration.

Company size: 1,001-5,000
Company stage: Not listed
Total funding: Not listed
Headquarters: Annapolis, MD
Founded: Not listed

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