RN Utilization Reviewer, Case Manager, Utilization Review

Rockville, MD
Oct 04, 2022
Oct 05, 2022
Full Time
Adventist Healthcare seeks to hire an experienced RN Case Manager (Utilization Review) who will embrace our mission to extend God's care through the ministry of physical, mental, and spiritual healing.

As an RN Case manager, you will:
•Perform real-time chart reviews in regards to compliance and physician documentation
•Collaborate with payors, care providers and review organizations to ensure proper utilization of patient care resources
•Review admission service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria
•Review patient records according to payor contractual agreements or as needed
•Provide education support and training for clinical staff regarding appropriate clinical documentation as well as guidelines for the Medicare 2 Midnight rule
•Communicate with third party payers and initial denials
•Interact with Physicians and Care Management staff, Admitting and Accounts Receivable staff on a daily basis and assists with trouble shooting issues on an ongoing basis
•Network with insurers to resolve denial issues that can be managed successfully without appeal
•Troubleshoot and resolve problems as they relate to the utilization of resources

Qualifications include:
•Graduate of an accredited nursing program, BSN
•Current Maryland RN license
•Minimum of 5 years recent nursing experience with a broad clinical nursing background
•Very strong computer and typing skills (35-40 wpm)
•2-5 years acute Case Management experience
•Experience in a Managed Care environment
•Case Management Certification-to achieve within 2-5 yrs
•Able to use medical necessity screening tools, such as InterQual/MCG
•Able to handle a multi task environment
•Maintains current literature on preadmission screening criteria and policies and procedures of insurance carriers

At Adventist HealthCare our job is to care for you. We do this by offering:
•Work life balance through non rotating shifts
•Recognition and rewards for professional expertise
•Competitive comprehensive benefit plans offered (including health, disability, PTO and 403B retirement plan with matching and 3 year vesting)
•100% Coverage for inpatient care - at Adventist HealthCare facilities
•100% Coverage for urgent care nationwide - after copay

As a faith-based organization, with over a century of caring for the communities in the Maryland area, Adventist HealthCare has earned a reputation for high-quality, compassionate care. Adventist HealthCare was the first and is the largest healthcare provider in Montgomery County.

If you want to make a difference in someone's life every day, consider a position with a team of professionals who are doing just that, making a difference.

Join the Adventist HealthCare team today! Apply now to be considered

Work Schedule:

Full Time remote

COVID-19 Vaccination

Adventist HealthCare requires all applicants to be fully vaccinated for COVID-19 before commencing employment. Applicants may be required to furnish proof of vaccination and , if offered, may elect to be vaccinated at a n designated Adventist HealthCare location.

Tobacco and Drug Statement

Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, Adventist HealthCare will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine and drug use.

While some jurisdictions, including Maryland, permit the use of marijuana for medical purposes, marijuana continues to be classified as an illegal drug under the federal Controlled Substances Act. As a result, medical marijuana use will not be accepted as a valid explanation for a positive drug test result.

Adventist HealthCare will withdraw offers of employment to applicants who test positive for Cotinine (nicotine) and marijuana. Those testing positive are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing.

Equal Employment Opportunity

Adventist HealthCare is an Equal Opportunity/Affirmative Action Employer. We are committed to attracting, engaging, and developing the best people to cultivate our mission-centric culture. Our goal is to have a welcoming, equitable, and safe place to work and grow for all employees, no matter their background. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.

Adventist HealthCare will make reasonable accommodations for applicants with disabilities, in accordance with applicable law. Adventist HealthCare is a religious organization as defined under applicable law; however, it will endeavor to provide reasonable accommodations for applicants' religious beliefs.

Applicants who wish to request accommodations for disabilities or religious belief should contact the Support Center HR Office.

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