Registered Nurse (Rn) Utilization Reviewer (Prn)

Located in Largo in the heart of Prince George’s County, our new state-of-the-art regional medical center (UM Capital Region Medical Center) provides improved access to primary and ambulatory care services, and serves as a tertiary care center for critically ill patients. In addition, our new space allows us to expand our offerings as a community partner to help improve the health status of Prince George’s County residents.

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. Staff assigned to this position are not scheduled to work sufficient hours to qualify for FLSA Exempt status.

Principal Responsibilities and Tasks

• Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
• Communicates with clinical care coordinators, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.
• 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.

• Licensure
  • 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 required
• Education
  • Bachelors in nursing is required.
• Experience
  • 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.
  • Proficient in MCG and/or Interqual and familiarity with the Code of Maryland Regulations (COMAR) is a plus.
  • Additional experience in home health, ambulatory care, and/or occupational health is preferred.
• Certification
  • Accredited Case Manager RN (ACM-RN) Preferred.
  • Certified Professional Utilization Reviewer (CPUR) preferred.

All your information will be kept confidential according to EEO guidelines.