Utilization Nurse Reviewer

4 weeks ago


Gaithersburg, Maryland, United States Adventist HealthCare Full time
Job Summary

Adventist HealthCare seeks a skilled Utilization Nurse Reviewer to join our Utilization Management department. As a key member of our team, you will play a critical role in ensuring the medical necessity of admission and compliance with reimbursement policy criteria.

Key Responsibilities
  • Review admission service requests for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.
  • Ensure compliance with Medicare and Medicaid regulatory requirements.
  • Collaborate with internal and external stakeholders, including physicians, healthcare teams, community providers, insurers, and others.
  • Network with insurers to resolve denial issues without appeal.
  • Interact with Physicians and Care Management staff, Admitting and Accounts Receivable staff daily to troubleshoot issues.
Requirements
  • 3-5 years of experience in acute care case management or UM activities.
  • Good understanding of CMS guidelines, including the Medicare 2-Midnight rule and MOON.
  • Maintains current knowledge/Certification in UM/CM, especially in relation to acute care hospital settings.
  • RN-BSN preferred, but RN-AA is acceptable.
  • Typing 50+ wpm and 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.
What We Offer
  • Competitive salary and benefits package.
  • Work-life balance through non-rotating shifts.
  • Medical, Prescription, Dental, and Vision coverage for employees and their eligible dependents.
  • Employer-paid Short & Long-Term Disability, Basic Life Insurance, and AD&D.
  • Employer retirement contribution and match after 1-year of eligible employment with a 3-year vesting period.
  • Voluntary benefits, including flexible spending accounts, legal plans, and life, pet, auto, home, long-term care, and critical illness & accident insurance.
  • Subsidized childcare at participating childcare centers.
  • Tuition Reimbursement.
  • Employee Assistance Program (EAP) support.

As a faith-based organization, Adventist HealthCare has earned a reputation for high-quality, compassionate care. We are committed to providing a healthy work environment and promoting a culture of excellence.



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