Job Description
Adventist Healthcare seeks to hire an experienced Utilization Nurse Reviewer for our Utilization Management department who will embrace our mission to extend God's care through the ministry of physical, mental, and spiritual healing.
As a Utilization Nurse Reviewer, you will:
• Conducts timely clinical chart reviews and applies appropriate clinical criteria according to department protocols, payer contractual agreements and/or as assigned. Provide effective communication with third party payers.
• Review admission service requests as assigned for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. Ensures compliance with Medicare and Medicaid regulatory requirements.
• Serve as an education and communication resource regarding utilization review, performance improvement and case mix reimbursement (DRG/Fee for service per practice area).
• Promotes quality care through the review of hospital resource utilization by reviewing medical necessity of admission, delays of care, costly resource use, and length of stay issues. Identify and isolate challenging Diagnosis Related Groups (DRGs), or other diagnoses or procedures and suggest methods for improvement
• Maintains effective working relationships with internal and external stakeholders including physicians, health care team, community providers, insurers and others.
• Review admission service requests within the assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.
• Interacts with Physicians and Care Management staff, Admitting and Accounts • Receivable staff daily and assists with troubleshooting issues on an ongoing basis.
• Networks with insurers to resolve those denial issues that can be managed successfully without appeal.
Qualifications include:
• InterQual/Milliman knowledge plus
• Analytical and critical thinking skills, time management skills
• Able to communicate and interact with all levels of professionals
• Good verbal and written communication, typing-use of Internet, email, and Windows environment
• 3-5 years of experience in acute care case management or UM activities is a plus.
• Good understanding of CMS guidelines (Medicare 2-Midnight rule, MOON
• Maintains current knowledge/Certification in UM/CM, especially in relation to acute care hospital setting
• Troubleshoots and resolves problems/issues as they relate to the utilization of resources.
• RN-BSN prefer but and RN-AA is acceptable, Typing 50+ wpm, 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
Work Schedule:
Day Shift-Remote
Some Holiday Coverage
#GR8 Other
Pay Range: $77,313.60 - $115,980.80
If the salary range is listed as $0 or if the position is Per Diem (with a fixed rate), salary discussions will take place during the screening process.
Under the Fair Labor Standards Act (FLSA), this position is classified as: United States of America (Exempt)
At Adventist HealthCare our job is to care for you. We do this by offering:
- Work life balance through nonrotating shifts
- Recognition and rewards for professional expertise
- Free Employee parking
- Medical, Prescription, Dental, and Vision coverage for employees and their eligible dependents effective on your date of hire
- Employer-paid Short & Long-Term Disability, Basic Life Insurance and AD&D, (short-term disability buy-up available)
- Paid Time Off
- Employer retirement contribution and match after 1-year of eligible employment with a 3-year vesting period
- Voluntary benefits include 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, with over a century of caring for the communities in the Maryland area, Adventist HealthCare has earned a reputation for high-quality, compassionate care. Adventist HealthCare was the first and is the largest healthcare provider in Montgomery County.
If you want to make a difference in someone's life every day, consider a position with a team of professionals who are doing just that, making a difference.
Join the Adventist HealthCare team today, apply now to be considered!
COVID-19 Vaccination Adventist HealthCare strongly recommends all applicants to be fully vaccinated for COVID-19 before commencing employment. Applicants may be required to furnish proof of vaccination.
Tobacco and Drug Statement Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, Adventist HealthCare will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine and drug use.
While some jurisdictions, including Maryland, permit the use of marijuana for medical purposes, marijuana continues to be classified as an illegal drug under the federal Controlled Substances Act. As a result, medical marijuana use will not be accepted as a valid explanation for a positive drug test result.
Adventist HealthCare will withdraw offers of employment to applicants who test positive for Cotinine (nicotine) and marijuana. Those testing positive are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing. ("Nicotine products" include, but are not limited to: cigarettes, cigars, pipes, chewing tobacco, e-cigarettes, vaping products, hookah, and nicotine replacement products (e.g., nicotine gum, nicotine patches, nicotine lozenges, etc.).
Equal Employment Opportunity Adventist HealthCare is an Equal Opportunity/Affirmative Action Employer. We are committed to attracting, engaging, and developing the best people to cultivate our mission-centric culture. Our goal is to have a welcoming, equitable, and safe place to work and grow for all employees, no matter their background. AHC does not discriminate in employment opportunities or practices on the basis of race, ethnicity, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, pregnancy and related medical conditions, protected veteran status, or any other characteristic protected by law.
Adventist HealthCare will make reasonable accommodations for applicants with disabilities, in accordance with applicable law. Adventist HealthCare is a religious organization as defined under applicable law; however, it will endeavor to provide reasonable accommodations for applicants' religious beliefs.
Applicants who wish to request accommodations for disabilities or religious belief should contact the Support Center HR Office. Adventist HealthCare
Job Tags
Holiday work, Temporary work, Flexible hours, Shift work, Night shift, Day shift,