MANAGER - UTILIZATION REVIEW - CARE MANAGEMENT - SINAI

Company: LifeBridge Health
Location: Baltimore
Posted on: May 28, 2023

Job Description:

Position Summary:
Responsible for the operational oversight related to utilization management, utilization review, and denial management for all commercial and government payers. Implements program to ensure reimbursement for services is secured as it relates to medical necessity and regulatory mandates for billing.

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  Provides operational direction, supervision, and oversight for staff performing utilization management, utilization review, and denial management functions for Sinai Hospital.
  
  
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  Ensures program support the reimbursement from commercial and government payers for clinical services provided at Sinai Hospital.
  
  
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  Assists the AVP of Care Management and Utilization Review in developing and maintaining effective utilization management programs within the context of the current healthcare landscape.
  
  
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  Identifies and shares trends related to compliance with appropriate status, medical necessity, appropriate utilization, and denials.
  
  
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  Engages with internal and external partners to support the outcome metrics for LBH Sinai Hospital strategies related to cost of care and quality.
  
  
  Qualifications/Requirements:
  
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    Basic professional knowledge; equivalent to a Bachelor's degree
    
    
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    Working knowledge of theory and practice within a specialized field
    
    
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    Nursing, Bachelor of Science (BSN) required
    
    
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    3-5 years of experience
    
    
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    Maryland Registered Nurse License
    
    
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    American Heart Association CPR Certification
    
    
    Prior experience as acute care case manager and/or hospital discharge planner required, working knowledge of medical necessity criteria in neonatal, pediatric, and adult population preferred. Willingness to attain Certified Case Manager or Accredited Case Manager credential within three years

Keywords: LifeBridge Health, Baltimore , MANAGER - UTILIZATION REVIEW - CARE MANAGEMENT - SINAI, Executive , Baltimore, Maryland