REMOTE Utilization Review Nurse - ED - 3 pm - 11 pm

Under general supervision, provides consultative support to the admitting teams concerning patient status determinations and utilization of resources for patients requiring hospital services. Works collaboratively with interdisciplinary teams 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.

GBMC is currently hiring a skilled Utilization Review Nurse for a full time REMOTE position. The scheduled hours will be from 3 pm - 11:30 pm.

Must be local, will need to come onsite monthly for scheduled meetings.

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.

Experience

Five (5) years diversified, progressive experience in acute care and/or other settings within the continuum required.

Two (2) years of Utilization  Management experience which includes utilization review processes and discharge planning preferred.

Knowledge, Skills and Abilities

• 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
• Strong analytical and problem solving skills
• Strong interpersonal communication skills
• Strong organizational and time management skills
• Proficiency in electronic medical record review

Licensures, Certifications

• Current state of Maryland Registered Nurse license
• Bachelor of Science in Nursing (BSN) OR documentation of current enrollment in BSN program with expected graduation within three years of hire
• Certification in Utilization Management and/or Care Management highly desired.

Physical Requirements

• Ability to sit, stand, stoop, and bend.

Working Conditions

• Primarily in an office environment, evaluating electronic medical records and performing electronic documentation and communication 70% of time.  Remainder of time working with interdisciplinary staff

Conditions of Employment

Maintain current licensure

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.

• Develops initial admission reviews for patients requiring hospital services and provides timely status recommendations to admitting providers in accordance with departmental and clinical guidelines. 

• Maintains a working knowledge of  contractual and clinical criteria guidelines. 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 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 consults with interdisciplinary team members to problem solve. 

• 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

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