Utilization Review Nurse for Case Management

General Summary

Provides utilization review and denials management for an assigned patient case load. This role utilizes MCG nationally recognized care guidelines/criteria to assess the patient’s need for outpatient or inpatient care as well as the appropriate level of care. The role requires interfacing with the case managers, medical team, other hospital staff, physician advisors and payers.

The Care Coordinator is responsible for the achievement of optimal health for the patient, access to care and appropriate utilization of resources. The patient’s plan of care will be balanced with their right to self-determination and patient/caregiver choice. The Care Coordinator, with respect to payer requirements, will ensure timely notification and communication of pertinent clinical data to support admission, clinical condition, continued stay and authorization of post-acute services.

Essential Functions of the job

The Care Coordinator will assess patients for clinical, psychosocial, financial and operational factors that may affect the progression of care. Using these criteria stratify patients at risk for over utilization of services and/or in need of care coordination services.

1. He/She will collaborate with clinical team to reduce inpatient length of stay and reduce readmissions across the organization
2. Performs and documents appropriate admission and continued stay reviews using current InterQual/Milliman Care Guidelines criteria on assigned patients.
3. Based on the health care team's assessment, patient choice and available resources, the care coordinator is develops a effective transition plan.
4. Actively participates in CTR rounds; interprets, and integrates the patient’s story into the overall multidisciplinary plan of care.
5. Develops and implements corrective action plans for resolution of complex problematic issues and elevates to management as necessary.
6. Documents appropriately per care coordination policy. Care coordination is responsible for documenting information that is not duplicative but instead is complementary and contributes to the progression of the plan of care.
7. Collaborates with Physician Advisor for complex issues related to the medical plan of care.
8. Actively participates in clinical performance improvement activities as assigned.
9. Remains current on clinical practice and protocols impacting clinical reimbursement

At Shore Regional Health, you can learn, grow and make a lasting impact on patients and families. You’ll experience the support of a collaborative work environment and a sense of collegiality unlike any other. Our comprehensive system has many locations and practice options to choose from throughout the beautiful Eastern Shore of Maryland.

Minimum Education, Experience, and License/Certification Required 

• Graduate of an approved registered nursing program with current RN license in the State of Maryland.
• Three years of experience in an acute care hospital.
• Experience in case management and/or utilization management preferred.
• Demonstrated excellent verbal and written communication, interpersonal and organizational skills required.
• Ability to work with Hospital/Utilization Management and related software programs is required.
• Experience with MGC and EPIC preferred.
• Knowledge of utilization management is preferred.

The employee in this position must be able to demonstrate the knowledge and skills necessary to provide care based on the age of the patients served.  He/she must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status, to interpret the appropriate information needed to identify each patient’s requirements relative to his/her age specific needs, and to provide the necessary care as described in the department’s policies and procedures.

All your information will be kept confidential according to EEO guidelines.

Compensation:

Pay Range: $40.61-$60.96

Other Compensation (if applicable):

Review the 2024-2025 UMMS Benefits Guide