Utilization Review Nurse

State of Maryland•Baltimore County, MD

2d•Hybrid

About The Position

This position is responsible for conducting reviews on admissions, continued stays, and readmissions, as well as managing the denial process. This position is vital to addressing the Maryland Department of Health (MDH) waitlist by identifying patients who no longer meet medical necessity criteria for inpatient care. These reviews are conducted independently of treatment teams to provide objective feedback to hospitals regarding patient progress. This position also manages the appeal process, working with the Physician Advisor when patients do not meet medical necessity criteria. Cases are presented to the Utilization Review to recommend the committee to determine if a second Physician Advisor review is required. This is a hybrid position that allows for teleworking. This position provides reports that identify opportunities to improve care through medical record reviews. These improvements may include the adequacy of documentation regarding patient progress, missing or insufficient records, the absence of required assessments, and the overall quality of treatment.

Requirements

Current license as a Registered Nurse from the Maryland State Board of Nursing or a current multi-state license.
Possession of a motor vehicle operator’s license valid in the State of Maryland (if assigned duties require operation of a vehicle).
Successful completion and maintenance of current cardiopulmonary resuscitation training (if required).
Provide a phone number at which they can be reached for call-ins.
Subject to substance abuse testing.

Nice To Haves

Experience using Google Suites (especially Google Sheets) to complete NRI statistics and maintain utilization review files and the UR database.
Experience in Risk Management.

Responsibilities

Conducting reviews on admissions, continued stays, and readmissions.
Managing the denial process.
Identifying patients who no longer meet medical necessity criteria for inpatient care to address the MDH waitlist.
Conducting reviews independently of treatment teams to provide objective feedback to hospitals regarding patient progress.
Managing the appeal process, working with the Physician Advisor when patients do not meet medical necessity criteria.
Presenting cases to the Utilization Review committee to determine if a second Physician Advisor review is required.
Providing reports that identify opportunities to improve care through medical record reviews, including adequacy of documentation, missing records, absence of required assessments, and overall quality of treatment.