Join Our Care Management – Where Innovation Meets Compassionate Care
Are you passionate about making a meaningful impact in both clinical and behavioral health? Our department stands out for its innovative, patient-centered approach and unwavering commitment to compassionate care. We are currently seeking a dedicated Utilization Reviewer to join our dynamic team.
Why Choose Capital Region?
If you’re looking for a workplace that values innovation, teamwork, and professional development, we invite you to be part of our journey.
Apply today and help us shape the future of behavioral health care.
Location: Largo, MD - Onsite
Hours: 8am- 4:30pm, rotating weekends and some holidays.
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.
Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
1. Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
2. Communicates with clinical care coordinators, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.
3. Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation.
4. Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg).
5. Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner.
6. Conducts HINN discussions/Observation Education.
7. Collaborates with Clinical Care Coordinators concerning Avoidable Days Collection.
8. Ensures Regulatory Compliance related to Utilization Management conditions of participation.
9. Assures appropriate reimbursement and stewardship of organizational and patient resources.
10. Pursues and reports opportunities to improve reimbursement.
11. Collaborates with admitting specialists regarding authorization policies and procedures of third party payers.
12. Remains current on clinical practice and protocols impacting clinical reimbursement.
Patient Safety
Ensures patient safety in the performance of job functions and through participation in hospital, department or unit patient safety initiatives.
1. Takes action to correct observed risks to patient safety.
2. Reports adverse events and near misses to appropriate management authority.
3. Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.
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 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. Certified Professional Utilization Reviewer (CPUR) preferred. Additional experience in home health, ambulatory care, and/or occupational health is preferred.
Knowledge, Skills and Abilities
1. Highly effective verbal and written skills are required.
2. Strong communication skills, self-confidence and experience in working with physicians are required.
3. Excellent analytical and team building skills, as well as the ability to prioritize and work independently are required.
4. The ability to work collaboratively with other disciplines is required.
5. Ability to work with Hospital/ Utilization Management and related software programs is required.
6. Knowledge of utilization management is preferred.
All your information will be kept confidential according to EEO guidelines.
Compensation
Like many employers, UMMS is being targeted by cybercriminals impersonating our recruiters and offering fake job opportunities. We will never ask for banking details, personal identification, or payment via email or text. If you suspect fraud, please contact us at careers@umms.edu.
At ABB, we help industries outrun - leaner and cleaner. Here, progress is an expectation - for you, your team, and the world. As a global market leader, we'll give you what you need to make it happen. It won't always be easy, growing takes grit. But at ABB, you'll never...
...MI ~ Training will take place in Traverse City and Cadillac Sleep Labs; the candidate must be willing and able to travel between... ...AAMA A-Step Module program. ~ The American Academy of Sleep Medicine (AAMA) A-Step program is an online program and will be funded through...
...Opportunity: Intern - Global Investments Salary Range:$18.75 -$30.00 per hour Company: Aflac Asset Mgt. LLC Division: Global Investment Recruiter: Alisha Hargrove Job Posting End Date: 2/9/2026 Worker Designation This role is hybrid ....
...grow as a person and as a professional, apply today! As Sous Chef, you will along with the Chef de Cuisine, lead a multi-cultural team... ...: Have a valid passport and C1/D Seaman's visa (DCL will provide you with documents to obtain this) Complete...
...Deputy Chief Information Officer (CIO) - Operations Print ( Apply ? Deputy Chief Information Officer (CIO) - Operations Salary... ...Officer - Technology Operations is a strategic executive leader who will provide guidance and leadership across the...