Utilization Review Nurse (Full-Time)

$68,281.18 - $110,274.20 / year

Under general supervision, provides consultative support to the admitting teams concerning patient status determinations and utilization of hospital resources facilitating quality, cost-effective patient outcomes for patients requiring hospital services. Works collaboratively with interdisciplinary staff internal and external to the organization facilitating appropriate status determinations through the utilization review process supporting quality, cost-effective patient outcomes. Responsible for analyzing clinical information and performing timely initial and concurrent reviews using InterQual screening software to identify appropriate medical necessity, length of stay, and level of care based upon evidence based clinical guidelines

Education:
Bachelor of Science in Nursing (BSN) OR Associate of Science in Nursing and currently enrolled in a BSN program with an expected graduation date within three (3) years.

Licensure, Certifications:

Current state of Maryland Registered Nurse license
Bachelor of Science in Nursing (BSN)
Certification in Utilization Management and/or Care Management highly desired.

Experience:
Five (5) years diversified, progressive experience in acute care and/or other settings within the continuum required.
Two (2) years of Utilization Review and Case Management experience which includes utilization review processes and discharge planning, and working with Re-Admission Initiatives preferred.
Skills:

· Advanced knowledge of InterQual and/or MCG admission criteria

· Knowledge of healthcare regulatory standards

· Advanced skill in using computer software

· Advanced skill in oral and written communication

· Advanced skill in critical thinking

· Ability to work independently and resolve complex problems

· Ability to remain calm under pressure and intense time constraints

· Ability to assess discharge needs for patients

· Strong analytical and problem-solving skills

· Strong interpersonal communication and influencing skills necessary to interact effectively with physicians, payers, regulatory agencies, staff, and other health professional

· Strong organizational and time management skills

· Ability to operate independently and balance multiple priorities

· Proficiency in electronic medical record review

Principal Duties and Responsibilities:

Reviews available electronic medical records during the pre-admission process to determine appropriate patient status, optimizing correct patient classification and corresponding payer notifications.

Reviews the appropriateness of admission and continued stay criteria for a defined group of patients
Develops initial admission reviews for patients requiring hospital services and provides timely status recommendations to admitting providers a concurrent stay and/or discharge plan of care in accordance with departmental and payer clinical guidelines.

Maintains a working knowledge of contractual and clinical criteria guidelines. Coordinates services with managed care companies and other third party payers. Discusses on-site reviewer issues with payer, either via the telephone or in person
Assures timely utilization compliance with all payers who require authorizations and clinical submission. Demonstrates knowledge of reimbursement mechanisms. Considers patient’s financial resources for meeting healthcare needs (insurance reimbursement, managed care plans, entitlement programs, and personal resources).

Participates as an active partner with physicians and interdisciplinary teams, providing education ancillary, and nursing staffregarding admission decisions including status determinations, financial and clinical outcomes, and documentation requirements and standards.

Maintains current knowledge on all regulatory changes that affect care delivery or reimbursement of acute care services. Uses
knowledge of national and local coverage determinations to appropriately advise physicians.

Identifies system obstacles that affect patient outcomes and participates in interdisciplinary decisions and care of the patient. consults with interdisciplinary team members to address problems, and makes recommendations to problem solve.
Assists with discharge planning, by preventing un-necessary hospital utilization, assist in the appropriate return of and placement of patients to post acute care, community based care and appropriate alternate levels of care.

Demonstrates mastery in InterQual level of care guidelines. Possesses proficiency in utilization review systems, clinical support systems, and business support applications.

Promotes use of evidence-based protocols to influence high quality and cost-effective care.

Escalates clinically and financially complex cases to leadership, offering possible solutions through discussion and feedback. Engages regularly in formal and informal dialogue about quality; directly addressing concerns and promoting continuous improvement.

Performs concurrent reviews and additional duties as assigned.

All roles must demonstrate GBMC Values:

Respect

I will treat everyone with courtesy. I will foster a healing environment.

Treats others with fairness, kindness, and respect for personal dignity and privacy

Listens and responds appropriately to others’ needs, feelings, and capabilities

Excellence

I will strive for superior performance in every aspect of my work. I will recognize and celebrate the accomplishments of others.

Meets and/or exceeds customer expectations
Actively pursues learning and self-development
Pays attention to detail; follows through

Accountability

I will be professional in the way I act, look and speak. I will take ownership to solve problems.

Sets a positive, professional example for others
Takes ownership of problems and does what is needed to solve them
Appropriately plans and utilizes required resources for various job duties
Reports to work regularly and on time

Teamwork

I will be engaged and collaborative. I will keep people informed.

Works cooperatively and collaboratively with others for the success of the team
Addresses and resolves conflict in a positive way
Seeks out the ideas of others to reach the best solutions
Acknowledges and celebrates the contribution of others

Ethical Behavior

I will always act with honesty and integrity. I will protect the patient.

Demonstrates honesty, integrity and good judgment
Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

Results

I will set goals and measure outcomes that support organizational goals. I will give and accept help to achieve goals.

Embraces change and improvement in the work environment
Continuously seeks to improve the quality of products/services
Displays flexibility in dealing with new situations or obstacles
Achieves results on time by focusing on priorities and manages time efficiently

Pay Range

$68,281.18 - $110,274.20

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

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