Utilization Review Nurse Hospital Compliance, Hybrid

Company Description

If relocating locally to Maryland, please note that in your application.

This position requires experience with utilization review in a hospital setting.

One team, One mission.

At the University of Maryland Medical System (UMMS), the health of Maryland is our mission — and our passion. We are the one health system that is focused on our state and delivering healthcare that’s made for Marylanders.

Being among the top 25 employers in the state and recently recognized as America’s Best Large Employer 2021 by Forbes, UMMS brings together a diverse and collaborative team of innovators committed to caring for our Marylanders, advancing medicine, and transforming lives. At UMMS, people are our priority – and that includes our patients, our community and our employees. We take your wellbeing, growth and work-life balance seriously.

(Hybrid schedule: work from home & office) 2 days in office, 3 days from home. Training will be in office.

The University of Maryland Medical System is a 14-hospital system with academic, community and specialty medical services reaching every part of Maryland and beyond. UMMS is a national and regional referral center for trauma, cancer care, Neurocare, cardiac care, women’s and children’s health and physical rehabilitation. UMMS is the fourth largest private employer in the Baltimore metropolitan area and one of the top 20 employers in the state of Maryland. No organization will give you the clinical variety, the support, or the opportunities for professional growth that you’ll enjoy as a member of our team. UMMS is currently seeking a Compliance Auditor at our corporate office in Linthicum, MD.

General Summary

Under general supervision, ensures that compliance initiatives are met for all the University of Maryland Medical System (UMMS) Member Organizations. Reviews and analyzes claims data, medical records, and billing and payment information to determine if charges and reimbursement are supported according to federal and state program guidelines. Significant contributor in the execution of the Corporate Compliance and Business Ethics Group (CCBEG) Auditing and Monitoring Plan. Contributes to the achievement of CCBEG goals and objectives and adheres to departmental policies, procedures, and standards.

Principal Responsibilities and Tasks

• Performs documentation and coding audits, reviewing medical records and charges to ensure compliance with CPT coding standards and the Centers for Medicare & Medicaid Services (CMS) conditions of coverage and guidelines.
• Works collaboratively with any department of UMMS and Member Organizations to research and resolve compliance investigations, including but not limited to, Member Organization Compliance Officers, Patient Financial Services, Reimbursement and Revenue Advisory Services, Health Information Management, Information Services and Technology, Case/Utilization Management, Quality, Pharmacy, Radiology, etc.
• Conducts analysis of findings to identify trends/problems in billing and documentation.
• Plans metrics from the Member Organization and developing reports for feedback to UMMS and the Member Organizations.
• Tracks and reports updates to coding and billing regulations.
• Performs other duties as assigned.
• In collaboration with CCBEG management, performs activities specified in the Auditing and Monitoring Plan.
• Provides input to CCBEG management and operational leaders to assist in the creation of management action plans to resolve identified deficiencies.
• Develops and administers coding and billing compliance training related to audit findings.
• Research applicable documentation and reimbursement policies to apply in the development of an audit plan for both scheduled and unscheduled UMMS Member Organization audits and investigations.
• Drafts written reports that detail audit findings and recommendations to senior UMMS leadership, Department management/personnel, and/or other related business partners.

Qualifications

Education and Experience

• Bachelor of Science degree in Business Administration, Hospital Administration, Accounting, Nursing, or related discipline.
• Certifications in one or more of the following is preferred: a) American Academy of Professional Coders (AAPC) Certifications: Certified Professional Coder (CPC), Certified Outpatient Coding (COC), Certified Inpatient Coder (CIC), and/or Certified Professional Medical Auditor (CPMA). b) American Health Information Management Association (AHIMA) Certification: Certified Coding Specialist (CCS)
• Five years of experience in clinical setting analyzing data and performing reviews such as utilization management, quality assurance, charge capture, coding, billing and medical necessity to facilitate correct claims submission to federal and state payers required.

Knowledge, Skills, and Abilities

• Basic understanding of Medicare program and Maryland Medical Assistance program models and website navigation to facilitate accurate issue spotting and development of guidance to organization is required.
• Requires ability to read and understand a patient’s medical record as it relates to clinical documentation and diagnostic/procedural coding of the services provided.

Additional Information

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