Utilization Management Specialist
Company: University of Maryland Medical System
Posted on: August 24, 2019
What You Will Do:
University of Maryland Medical Center(UMMC) has achieved Magnet
status in recognition of the hospital nursing excellence. UMMC is a
teaching hospital with 757 beds based in Baltimore, Maryland, that
provides the full range of health care. It has more than 35,000
inpatient admissions and 165,000 outpatient visits each year. The R
Adams Cowley Shock Trauma Center (also known as Shock Trauma) is
the world's first center dedicated to saving lives of people with
severe, life-threatening injuries sustained in motor vehicle
collisions, violent crimes and other traumatic incidents. Our
vision is to provide high value and compassionate care, improving
health in Maryland and beyond, educating future health care leaders
and discovering innovative ways to advance medicine worldwide.
Be Part of Something Greater!
I. General Summary
Under general supervision, provides utilization review and denials
management for an assigned patient case load. This role utilizes
nationally recognized care guidelines/criteria to assess the
patient's need for outpatient or inpatient care as well as the
appropriate level of care. The role requires interfacing with the
case managers, medical team, other hospital staff, physician
advisors and payers.
II. Principal Responsibilities and Tasks
The following statements are intended to describe the general
nature and level of work being performed by staff assigned to this
classification. They are not to be construed as an exhaustive list
of all job duties performed by personnel so classified.
- Performs timely and accurate utilization review for all patient
populations, using nationally recognized care guidelines/criteria
relevant to the payer.
- Communicates with case manager, physician advisor, medical team
and payors as needed regarding reviews and pended/denied days and
- Supports concurrent appeals process through proactive
identification of pended/denied days. Implements the concurrent
appeals process with appropriate referrals and documentation.
- Ensures appropriate Level of Care and patient status for each
patient (Observation, Extended Recovery, Administrative, Inpatient,
Critical Care, Intermediate Care, and Med-Surg)
- Reviews tests, procedures and consultations for appropriate
utilization of resources in a timely manner
- HINN discussions/Observation Education
- Assists Case Manager in Avoidable Days Collection
- Ownership of Regulatory Compliance related to Utilization
Management conditions of participation
- Assures appropriate reimbursement and stewardship of
organizational and patient resources.
- Actively reports opportunities to improve reimbursement and
responds to relevant data
- Collaborates with admitting specialists regarding authorization
policies and procedures of third party payers.
- Remains current on clinical practice and protocols impacting
What You Need to Be Successful:
III. Education and Experience
- Bachelors in Nursing required. Licensure as a Registered Nurse
in the state of Maryland, or eligible to practice due to Compact
state agreements outlined through the MD Board of Nursing, is
- One year of experience in case management or utilization
management with knowledge of payer mechanisms and utilization
management is preferred. Two years experience in acute care and
four years clinical healthcare experience preferred. Certified
Professional Utilization Reviewer (CPUR) preferred. Additional
experience in home health, ambulatory care, and/or occupational
health is preferred.
We are an Equal Opportunity/Affirmative Action employer. All
qualified applicants will receive consideration for employment
without regard to sex, gender identity, sexual orientation, race,
color, religion, national origin, disability, protected veteran
status, age, or any other characteristic protected by law.
Keywords: University of Maryland Medical System, Chantilly , Utilization Management Specialist, Executive , Parkville, Virginia
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