What are the responsibilities and job description for the UTILIZATION REVIEW NURSE PRN position at LifeBridge Health?
Summary
JOB SUMMARY: Conducts initial, concurrent, and retrospective chart review for clinical, financial and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment. Interfaces with 3rd party payers by providing pertinent, relevant clinical information.
*This is a PRN Weekend position that will be scheduled for Saturday and/or Sunday shifts as needed.*
RESPONSIBILITIES:
The Utilization Review RN reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource consumption. Enters clinical reviews into the software program. Maintains close communication with external reviewers/internal financial counselors/patient access personnel and performs certification activities as required by payor. Monitors and identifies patterns or trends in utilization management. Monitors potential and actual denials and coordinates with nurse Care Manager and/or Social Worker for any follow up necessary. Documents in software program the actions taken to coordinate care and avoid denials. Assists nurse Care Managers in communicating with the patient denied hospital days as well as the issuance of Medicare forms including HINN, Detailed Notice of Discharge to patients/family/significant other when they are in disagreement with the discharge plan arranged by attending and Care Management personnel. Coordinates with the Care Manager to achieve optimal and efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. Utilizes Physician Advisor and administrative personnel for unresolved issues. Identifies opportunities for expedited appeals and collaborates with the Care Manager and Physician Advisor to resolve payer issues. Other tasks as assigned. Sends appropriate referrals/escalations to the physician advisors to review case not met with criteria.
REQUIREMENTS:
- BSN preferred; ADN required
- 3-5 years of Utilization Review experience required
- Registered Nurse License - Current Maryland license or eligibility to obtain Maryland license
Additional Information
As one of the largest health care providers in Maryland, with 13,000 team members, We strive to CARE BRAVELY for over 1 million patients annually. LifeBridge Health includes Sinai Hospital of Baltimore, Northwest Hospital, Carroll Hospital, Levindale Hebrew Geriatric Center and Hospital and Grace Medical Center, as well as our Community Physician Enterprise, Center for Hope, Practice Dynamics, and business partners: LifeBridge Health & Fitness, ExpressCare and HomeCare of Maryland.
