Utilization Review Nurse RN

Schedule

• Full-time, Day shift – 8:00 am to 4:30 pm

Conducts initial, concurrent, and retrospective chart reviews to evaluate clinical, financial, and resource utilization. Provides intervention and coordination to reduce avoidable delays and payment denials and interfaces with third‑party payers to supply pertinent clinical information.

• Review medical records using utilization review criteria to assess clinical, financial, and resource consumption.
• Enter clinical reviews into the software program and document actions taken to coordinate care and avoid denials.
• Maintain close communication with external reviewers, internal financial counselors, patient access personnel, and perform certification activities as required by payors.
• Monitor patterns and trends in utilization management, identify potential and actual denials, and coordinate follow‑up with nurse Care Managers and/or Social Workers.
• Assist nurse Care Managers in communicating with patients denied hospital days and in issuing Medicare forms, including HINN and Detailed Notice of Discharge, when patients dispute the discharge plan.
• Coordinate with Care Managers to achieve optimal patient outcomes, reduce length of stay, and prevent delays and denied days.
• Utilize Physician Advisors and administrative personnel to resolve unresolved issues and identify opportunities for expedited appeals.
• Send appropriate referrals or escalations to physician advisors for cases not meeting criteria.
• Complete other assigned tasks as required.

• Registered Nurse License – current Maryland license or eligibility to obtain one.
• Associate’s Degree in Nursing required; BSN or higher preferred.
• Minimum of 3 years of related experience.

• Competitive compensation, including overtime, shift differentials, premium pay, and bonuses (may apply).
• Comprehensive health plans.
• Free parking.
• Wellness programs.

Life Bridge Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression. Life Bridge Health does not exclude people or treat them differently because of race, color, national origin, age, disability, sex or sexual orientation, and gender identity/expression.