Utilization Management Nurse - PreBill & Denials

Utilization Management Nurse - PreBill & Denials (remote) Anne Arundel Medical Center, Annapolis, MD Full Time - Day shift (M-F, 8a-4:30p, rotating weekends) Status: Non-exempt/hourly Remote work is approved only for locations in the following states: Maryland, Pennsylvania, Washington D.C., West Virginia, Virginia, Tennessee, Texas, North Carolina, South Carolina, Georgia, Florida Position Objective: Conducts concurrent and retrospective chart review for clinical, financial, and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment.

Chart Review: Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC Denial Management: Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge. Care Coordination: Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues. Process improvement initiatives: Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.