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Key skills for this role
Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource utilization; enters clinical review in EPIC; maintains close communication with external reviews, care coordinators, and providers; reconciles and records days authorized in EPIC
Monitors and identifies patterns or trends in utilization management; monitors potential and actual denials and collaborates with care coordinator for any follow up necessary; documents actions taken to avoid denial; assists Care Coordinator in communicating with the patient denied hospital days with work toward resolution and discharge.
Collaborates with the Care Coordinator to achieve optimal and efficient patient outcomes while decreasing length of stay, avoidable delays and denied days; utilizes Physician Advisor and administrative personnel for unresolved issues; identifies opportunities for expedited appeals and collaborates with the care coordinator and Physician Advisor to resolve payer issues.
Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.
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There is a reasonable expectation that employees in this position will be exposed to blood-borne pathogens.
Physical Demands -
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.
Luminis Health Benefits Overview: • Medical, Dental, and Vision Insurance • Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year) • Paid Time Off • Tuition Assistance Benefits • Employee Referral Bonus Program • Paid Holidays, Disability, and Life/AD&D for full-time employees • Wellness Programs • Employee Assistance Programs and more *Benefit offerings based on employment status
Opt-in for text notifications! Luminis Health's two-way SMS texting platform lets you receive notifications and messages from our Talent Acquisition team directly on your phone. To enable this feature, select "yes" when asked to "opt-in to receive text messages" and to "Receive updates from a recruiter about this job via SMS" when completing your application. Once you are opted in, you can easily opt-out at any time. Standard text messaging rates may apply based on the candidate's mobile carrier plan. Luminis Health is not responsible for any charges incurred by the recipient. Candidates are encouraged to review their mobile carrier's plan for applicable text messaging rates and usage charges.
Nonprofit regional health system serving Maryland.
Visit company websiteJobs and hiring trendsUSD 34-55 hourly / hour
Full-time
Mid · 3+ years experience
Hybrid
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