Utilization Review Specialist

2 days ago


Upper Marlboro, Maryland, United States University of Maryland Medical System Full time
Job Summary

We are seeking a highly skilled Utilization Reviewer to join our team at the University of Maryland Medical System. As a Utilization Reviewer, you will play a critical role in ensuring that our patients receive the most appropriate level of care while also optimizing resource utilization.

Key Responsibilities
  • Conduct timely and accurate utilization reviews for all patient populations, utilizing nationally recognized care guidelines and criteria.
  • Communicate effectively with clinical care coordinators, physician advisors, medical teams, and payers to ensure seamless coordination of care.
  • Support the concurrent appeals process by proactively identifying pended/denied days and implementing interventions as needed.
  • Ensure accurate Level of Care and patient status for each patient, including Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg.
  • Review tests, procedures, and consultations for optimal resource utilization and timely completion.
  • Collaborate with Clinical Care Coordinators to identify opportunities for Avoidable Days Collection.
  • Ensure Regulatory Compliance related to Utilization Management conditions of participation.
  • Pursue and report opportunities to improve reimbursement and optimize resource utilization.
Requirements
  • Licensure as a Registered Nurse in the state of Maryland or eligible to practice due to Compact state agreements.
  • Bachelor's degree in Nursing required.
  • One year of experience in case management or utilization management, with knowledge of payer mechanisms and utilization management preferred.
  • Strong analytical and team building skills, with the ability to prioritize and work independently.
  • Excellent communication skills, with the ability to work collaboratively with other disciplines.
What We Offer

We offer a competitive salary and benefits package, as well as opportunities for professional growth and development. If you are a motivated and detail-oriented individual with a passion for healthcare, we encourage you to apply for this exciting opportunity.



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