Utilization Review Nurse RN

Sinai Hospital's Utilization Review operates as a distinct specialty service line of physician advisors, nurses, and support staff who ensure hospital stays are clinically appropriate and fully covered by the patient's insurance. The team focuses on appropriate resource use, operational efficiency, and timely patient services while maintaining or improving quality of care.

Summary:
Conducts initial, concurrent and retrospective chart review for clinical, financial and resource utilization information. Provides intervention and coordination to decrease avoidable delays and denial of payment. Interfaces with 3rd party payers by providing pertinent, relevant clinical information.

This is a Full-time remote position.

Responsibilities:

The Utilization Review RN reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource consumption. Enters clinical reviews into the software program. Maintains close communication with external reviewers/internal financial counselors/patient access personnel and performs certification activities as required by payor. Monitors and identifies patterns or trends in utilization management. Monitors potential and actual denials and coordinates with nurse Care Manager and/or Social Worker for any follow up necessary. Documents in software program the actions taken to coordinate care and avoid denials. Assists nurse Care Managers in communicating with the patient denied hospital days as well as the issuance of Medicare forms including HINN, Detailed Notice of Discharge to patients/family/significant other when they are in disagreement with the discharge plan arranged by attending and Care Management personnel. Coordinates with the Care Manager to achieve optimal and efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. Utilizes Physician Advisor and administrative personnel for unresolved issues. Identifies opportunities for expedited appeals and collaborates with the Care Manager and Physician Advisor to resolve payer issues. Other tasks as assigned. Sends appropriate referrals/escalations to the physician advisors to review case not met with criteria.

Qualifications:

Education: BSN preferred; ADN required

Experience: 3-5 years of Utilization Review experience required; preferably in acute hospital setting

Licensure: Registered Nurse License - Current Maryland license or eligibility to obtain Maryland license

Pay Range: $40.12 to $62.19 Based On Experience

About Sinai Hospital

Sinai Hospital of Baltimore is a nationally recognized academic medical center, a designated Level II Trauma Center, and the largest community hospital in Maryland. As part of LifeBridge Health - one of the region's most comprehensive healthcare systems - Sinai delivers advanced care with a mission to improve the health of the communities we serve, and to take care of the people who take care of patients.