Utilization Review Nurse (Remote), Day Shift, Utilization Management
Support Center If you are a current Adventist HealthCare employee, please click this link to apply through your Workday account. Adventist HealthCare seeks to hire an experienced Utilization Review Nurse who will embrace our mission to extend God's care through the ministry of physical, mental, and spiritual healing. As a Utilization Review Nurse, you will:
- Conducts timely clinical chart reviews and applies appropriate clinical criteria according to department protocols, payer contractual agreements, and/or as assigned. Provide effective communication with third-party payers.
- Reviews admission service requests as assigned for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. Ensures compliance with Medicare and Medicaid regulatory requirements.
- Serve as an education and communication resource regarding utilization review, performance improvement, and case mix reimbursement (DRG/Fee for service per practice area).
- Promotes quality care through the review of hospital resource utilization by reviewing medical necessity of admission, delays of care, costly resource use, and length of stay issues. Identify and isolate challenging Diagnosis-Related Groups (DRGs), or other diagnoses or procedures, and suggest methods for improvement
- Maintains effective working relationships with internal and external stakeholders to include physicians, health care team, community providers, insurers and others.
- Reviews admission service requests within the assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.
- Interacts with Physicians and Care Management staff, Admitting and Accounts Receivable staff daily, and assists with troubleshooting issues on an ongoing basis.
- Networks with insurers to resolve those denial issues that can be managed successfully without appeal.
Qualifications include:
- InterQual/Milliman knowledge plus
- Analytical and critical thinking skills, time management skills
- Able to communicate and interact with all levels of professionals
- Good verbal and written communication, typing-use of the Internet, email, Windows environment
- 3-5 years' experience in acute care case management or UM activities is a plus.
- Good understanding of CMS guidelines (Medicare 2-Midnight rule, MOON
- Maintains current knowledge/Certification in UM/CM, especially in relation to acute care hospital setting
- Troubleshoots and resolves problems/issues as they relate to the utilization of resources.
- RN-BSN preferred, but RN-AA acceptable. Typing 50+ wpm, strong computer skills
- 3-5 years in Utilization Review and Case Management Discharge planning
- DC License Required if assigned to HUH, MD License, or compact per state policy
Work Schedule: M-F, occassional holidays Pay Range: $77,313.60 - $115,980.80 If the salary range is listed as $0 or if the position is Per Diem (with a fixed rate), salary discussions will take place during the screening process. Under the Fair Labor Standards Act (FLSA), this position is classified as: United States of America (Exempt) At Adventist HealthCare our job is to care for you. We do this by offering:
- Work life balance through nonrotating shifts
- Recognition and rewards for professional expertise
- Free Employee parking
- Medical, Prescription, Dental, and Vision coverage for employees and their eligible dependents effective on your date of hire
- Employer-paid Short & Long-Term Disability, Basic Life Insurance and AD&D, (short-term disability buy-up available)
- Paid Time Off
- Employer retirement contribution and match after 1-year of eligible employment with a 3-year vesting period
- Voluntary benefits include flexible spending accounts, legal plans, and life, pet, auto, home, long term care, and critical illness & accident insurance
- Subsidized childcare at participating childcare centers
- Tuition Reimbursement
- Employee Assistance Program (EAP) support
As a faith-based organization, with over a century of caring for the communities in the Maryland area, Adventist HealthCare has earned a reputation for high-quality, compassionate care. Adventist HealthCare was the first and is the largest healthcare provider in Montgomery County. If you want to make a difference in someone's life every day, consider a position with a team of professionals who are doing just that, making a difference. Join the Adventist HealthCare team today, apply now to be considered! COVID-19 Vaccination Adventist HealthCare strongly recommends all applicants to be fully vaccinated for COVID-19 before commencing employment. Applicants may be required to furnish proof of vaccination. Tobacco and Drug Statement Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, Adventist HealthCare will not hire applicants for employm