Adventist HealthCare

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

Posted on

March 8, 2025

Job Type

Full-Time

Role Type

Utilization Review

License

RN

State License

Maryland

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Company Description

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.

Job Description

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.

Requirements

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 Internet, email, and Windows environment 3-5 years of 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 prefer but and RN-AA is 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

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Responsibilities

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.

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