Clinical Utilization Specialist

2 days ago

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

Under general supervision, the Utilization Reviewer provides timely and accurate utilization review for all patient populations, utilizing nationally recognized care guidelines/criteria relevant to the payer. This role requires interfacing with the case managers, medical team, other hospital staff, physician advisors, and payers.

Key Responsibilities
  • Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
  • Communicates with clinical care coordinators, physician advisor, medical team, and payers as needed regarding reviews and pended/denied days and interventions.
  • Supports concurrent appeals process through proactive identification of pended/denied days, implementing the concurrent appeals process with appropriate referrals and documentation.
  • Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg).
  • Reviews tests, procedures, and consultations for appropriate utilization of resources in a timely manner.
  • Conducts HINN discussions/Observation Education.
  • Collaborates with Clinical Care Coordinators concerning Avoidable Days Collection.
  • Ensures Regulatory Compliance related to Utilization Management conditions of participation.
  • Assures appropriate reimbursement and stewardship of organizational and patient resources.
  • Pursues and reports opportunities to improve reimbursement.
  • Collaborates with admitting specialists regarding authorization policies and procedures of third-party payers.
  • Remains current on clinical practice and protocols impacting clinical reimbursement.
Qualifications
  • Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required.
  • Bachelor's in Nursing required.
  • One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred.
  • Two years' experience in acute care and four years' clinical healthcare experience preferred.
  • Certified Professional Utilization Reviewer (CPUR) preferred.
Knowledge, Skills, and Abilities
  • Highly effective verbal and written skills are required.
  • Strong communication skills, self-confidence, and experience in working with physicians are required.
  • Excellent analytical and team-building skills, as well as the ability to prioritize and work independently, are required.
  • The ability to work collaboratively with other disciplines is required.
  • Ability to work with Hospital/Utilization Management and related software programs is required.

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