Utilization Nurse Reviewer (Remote), Day Shift, Utilization Management

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.

Adventist Healthcare seeks to hire an experienced Utilization Nurse Reviewer for our Utilization Management department who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing.

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. Review 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 including physicians, health care team, community providers, insurers and others. Review 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.