Utilization Management Nurse - Emergency Department

<p><strong>Position Objective:</strong>&nbsp;&nbsp;Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment. &nbsp;</p> <p><strong>Essential Job Duties:</strong></p> <p><strong>1. Chart Review</strong>:</p> <p>Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC</p> <p><strong>2. Denial Management</strong>:</p> <p>Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial;&nbsp; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge.</p> <p><strong>3. Care Coordination:</strong></p> <p>Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues.</p> <p><strong>4.&nbsp; Process improvement initiatives</strong></p> <p>Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.</p> <p><strong>Educational/Experience Requirements:</strong></p> <ul> <li><span class="xui-provider">Bachelor’s of Science in Nursing or Associate’s degree in Nursing with equivalent experience. &nbsp;BSN must be achieved within 5 years of start date in the role.&nbsp;&nbsp;</span></li> <li>Three&nbsp;years of clinical nursing in an acute care hospital setting.</li> </ul> <p><strong>Required</strong><strong>License/Certifications:</strong></p> <ul> <li>Current RN license from Maryland Board of Nursing.</li> </ul> <p><strong>Working Conditions, Equipment, Physical Demands:</strong></p> <p>There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.</p> <p>Physical Demands -</p> <p><strong>The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential