Medical Claims Review Manager jobs in Maryland

General Summary

This is a PRN position with a requirement to work a minimum 2 weekend shifts per month & 1 holiday per year.

MUST have 3-5  years clinical experience in a healthcare setting and have previous Utilization Management experience.

Under general supervision, provides utilization review 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

1. Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
2. Communicates with case management team, medical team, and payors as needed regarding reviews and pended/denied days and interventions.
3. Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg).
4. Reviews tests, procedures, and consultations for appropriate utilization of resources in a timely manner.

Our growing community hospital serving Maryland’s Charles County offers all of the services and amenities of a bigger metro hospital with the personal attention of our caring staff. At University of Maryland Charles Regional Medical Center (UM CRMC), our talented and diverse groups of professionals represent our strength. Through teamwork and a collaborative work environment, we proudly serve our patients and our community with unwavering commitment. It’s our passion for people that motivates us to do great work every single day.

We are consistently named among the top 100 Best Places to Work in Maryland. Employees have the opportunity to grow professionally in a supportive and stimulating environment. Our excellent employee benefits support a healthy, balanced lifestyle.

• 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
  • Bachelor in Nursing preferred
• Experience
  • Three - Fove years clinical experience in a healthcare setting and have previous utilization management experience.

All your information will be kept confidential according to EEO guidelines.