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Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

**LOCATION:** Fully remote position after 12-week onsite orientation

**HOURS:** Full Time (40 hours per week). Monday-Friday, one weekend every 11 weeks. Flexible start time from 6:30am-9am. No holidays

_Penn Medicine Lancaster General Health is looking for an experienced RN to join our Utilization Management Specialist team! In this critical role, you’ll advocate for patients by conducting thorough chart reviews, communicating with payors to secure timely authorizations, and ensuring accurate patient status throughout their stay. You’ll collaborate closely with physicians, clinical staff, and financial teams to support optimal outcomes and minimize denials—all while meeting tight deadlines in a fast-paced acute care environment. If you have deep clinical knowledge, strong decision-making skills, and thrive under pressure, we’d love to hear from you!_

**Summary** : The Utilization Management Specialist - Admissions is responsible for evaluating medical records to determine severity of patient's illness and the appropriate patient class in accordance with industry guidelines. Serves as a liaison for patients and hospital with insurance companies.

Qualified individuals must have the ability with or without reasonable accommodation to perform the following duties:

+ Complete chart review and communicate patient status medical needs with insurance companies in order to advocate for patients and facilitate appropriate reimbursement while meeting tight payor deadlines, often less than 24 hours.

+ Amend patient status and complete order requests to Attending Physician/Advance Practice Provider urgently.

+ Deep and thorough knowledge of clinical process in the Acute Care setting with the ability to make bold, independent decisions in regard to patient status and authorization requests.

+ Ensure that patients are assigned the appropriate patient class throughout patient stay by using Industry standard review tools, department policies, and critical thinking.

+ Frequently coordinate with clinical staff to facilitate appropriate documentation to support patient class, optimal patient outcomes, and minimize denied days.

+ Work closely with physician advisers to provide timely, accurate and thorough clinical reviews to assist in patient class decision-making process.

+ Ability to handle an unpredictable workload shaped by census and payor demands. Must be able to complete assignment by end of day to comply with department standards and payor requests.

+ Complete all documentation, including authorizations and denials according to departmental standard operating procedures.

+ Communicate with Patient Financial Services staff regarding changes to patient class to ensure proper billing. Work with Financial Clearance and Registration staff to ensure proper billing.

+ Facilitate Peer to Peer appeal processes post-denial in a timely fashion.

+ Follow up with payers to account for all bed days for authorization prior to discharge.

+ Maintain knowledge of specific payer requirements to ensure efficient review process.

+ Serve as a point of contact subject matter expert in the process of outside facilities transferring patients to Lancaster General Hospital.

The following duties are considered secondary to the primary duties listed above:

+ Participates in Continuous Improvement for the department and the organization.

+ Identifies professional needs to maintain expertise and keep current with health care trends, both clinical and financial.

+ Participates in orientation and education of individuals to the functions of this position.

+ Participate in weekend coverage based on department rotation

+ Other duties as assigned.

Minimum Required Qualifications:

+ Current licensure as a Registered Nurse, issued by the Pennsylvania Board of Nursing

+ Bachelor’s of Science in Nursing

+ Minimum of five years of nursing experience which includes a minimum of three years in an acute care hospital setting

+ Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical chart review efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Ability to advocate for the patient, as well as the hospital’s best interests.

+ Ability to adjust adapt to varying needs of the department and the ever-changing industry requirements

+ Ability to work independently and exercise sound judgment in interactions with the health care team

+ Ability to tolerate high volume production standards.

Preferred Qualifications:

+ Knowledge of health care and managed care delivery systems. This includes standards of medical practice; insurance benefit structures and related legal medical issues.

+ Knowledge of utilization management and quality improvement processes.

+ Experience working within the managed care environment.

\#LI-LJ1

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

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