Utilization Review Registered Nurse​/on-call

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 Inter Qual screening software to identify appropriate medical necessity, length of stay, and level of care based upon evidence based clinical guidelines.

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.

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

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.

• Advanced knowledge of Inter Qual 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

• 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 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 staff regarding 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 unnecessary hospital utilization, and assists 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 Inter Qual 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, Excellence, Accountability, Teamwork, Ethical…