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General Summary of Position
The primary responsibility of the Utilization Review (UR) and Denials Management Nurse is to utilize clinical expertise to interface with contracted third party vendor, VPMA or designated Physician Advisor, Providers, case management staff and other associates to facilitate timely review of the appropriateness and medical necessity of the treatments, services, procedures, and facilities provided to patients on a case-by-case basis and to support optimal hospital throughput and appropriate reimbursement for services rendered. Primary Duties and Responsibilities
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.In collaboration with appropriate parties, analyzes medical records to ensure proper placement in inpatient, observation or administrative (H) status during hospitalization and to prepare for appeal of insurance and/or third-party payer denials. Utilizes Explanation of Benefits, Hospital Patient account systems and Remittance Advises to verify denial and package information for internal or third party appeal.Facilitates effective evaluation of appropriateness of medical services through prospective, concurrent and retrospective review processes.Coordinates appeal process and maintain appropriate follow-up on appealed claims and contact information.Maintains appropriate documentation via electronic databases.Reports regularly to the Director/Physician Advisor on UR and clinical denial activities, including decisions for 2nd level appeal in UR and managing overturn rate data and continually evaluating for improvement.Implements appeal process for denied days for medical necessity that meets national criteria standards or appear to be clinically justified.Utilizes and analyzes current medical/clinical information as well as medical record information to initiate appeal letters.Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action, where indicated.Identifies strategies to improve efficiency in delivery of care through review and examination of UR status and denials. Identifies process issues related to the concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management.Participates in multi-disciplinary quality and service improvement teams.Participates in meetings and on committees and represents the department and hospital in community outreach efforts.Participates in multi-disciplinary quality and service improvement teams.
Minimum Qualifications
Education
- Graduation from an accredited School of Nursing required and
- Bachelor's degree in Nursing preferred
Experience
- 3-4 years experience in denial management required and
- knowledge of Utilization Review required
Licenses and Certifications
- RN - Registered Nurse - State Licensure and/or Compact State Licensure in the State of Maryland Upon Hire required
Knowledge, Skills, and Abilities
- Computer skills (Microsoft Office, Outlook, Internet, typing skills) required; able to adapt to required software programs which support Utilization Management functions. Familiarity with health care documentation systems.
Creative problem-solving skills and a strong attention to detail and accuracy required.
Possess knowledge of managed care insurance, governmental health programs, HMO's and their impact on hospital and post hospital care reimbursement.
Must be able to work independently, anticipate and organize workflow, prioritize and follow through on responsibilities.
Superior organization and time management skills required; able to skillfully manage a high-volume caseload and to respond effectively to rapidly changing priorities.
This position has a hiring range of $87,318 - $157,289
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MedStar Health
Apr 04, 2025