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 criteriaKnowledge of healthcare regulatory standardsAdvanced skill in using computer softwareAdvanced skill in oral and written communicationAdvanced skill in critical thinkingAbility to work independently and resolve complex problemsAbility to remain calm under pressure and intense time constraintsStrong analytical and problem solving skillsStrong interpersonal communication skillsStrong organizational and time management skillsProficiency in electronic medical record review

Licensures, Certifications

Current state of Maryland Registered Nurse licenseBachelor of Science in Nursing (BSN) OR documentation of current enrollment in BSN program with expected graduation within three years of hireCertification 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

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

Treats others with fairness, kindness, and respect for personal dignity and privacyListens 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 expectationsActively pursues learning and self-developmentPays 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 othersTakes ownership of problems and does what is needed to solve themAppropriately plans and utilizes required resources for various job dutiesReports 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 teamAddresses and resolves conflict in a positive waySeeks out the ideas of others to reach the best solutionsAcknowledges 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 judgmentRespects 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 environmentContinuously seeks to improve the quality of products/servicesDisplays flexibility in dealing with new situations or obstaclesAchieves results on time by focusing on priorities and manages time efficiently

COVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.

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.