The Utilization Review Nurse RN 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.
Responsibilities Include: 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 cases not met with criteria
Registered Nurse License - Current Maryland license or eligibility to obtain Maryland license Associate's Degree in Nursing required; BSN or higher preferred Minimum of 3 years of related experience
$40.12 to $62.19 Based On Experience
Medical, dental, and vision coverage starting the first of the month after hire, plus wellness programs and mental health support 403(b) retirement plan with employer match, pension, and life and disability insurance Tuition reimbursement toward advanced degrees and specialty certifications Generous paid time off, fitness discounts, and free on-site parking About Northwest Hospital Northwest Hospital is a full-service community hospital in Baltimore County serving Randallstown, Pikesville, Owings Mills, and beyond.
As part of LifeBridge Health - one of the region's most comprehensive healthcare systems - Northwest delivers compassionate, high-quality care close to home, with a mission to improve the health of the communities we serve, and to take care of the people who take care of patients. About LifeBridge Health LifeBridge Health is a dynamic, purpose-driven health system redefining care delivery across the mid-Atlantic and beyond, anchored by our mission to "improve the health of people in the communities we serve." Join us to advance health access, elevate patient experiences, and contribute to a system that values bold ideas and community-centered care.
With over 14,000 employees, 130 care locations, and two million annual patient encounters, we combine strategic growth, innovation, and deep community commitment to deliver exceptional care anchored by five leading centers in Maryland. Our organization thrives on a culture of CARE BRAVELY-where compassion, courage, and urgency drive every decision, empowering teams to shape the future of healthcare. LifeBridge Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression.
LifeBridge Health does not exclude people or treat them differently because of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression.