Utilization Review Nurse (Full-Time)

About the Role

Provides consultative support to 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 to facilitate appropriate status determinations through the utilization review process, supporting quality, cost-effective patient outcomes.

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, 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 payers, either via telephone or in person.
• Ensures timely utilization compliance with all payers who require authorizations and clinical submission.
• Demonstrates knowledge of reimbursement mechanisms and 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 to ancillary and nursing staff regarding admission decisions, including status determinations, financial and clinical outcomes, and documentation requirements and standards.
• Maintains current knowledge of all regulatory changes that affect care delivery or reimbursement of acute care services and 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 facilitating the appropriate return 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 and possesses proficiency in utilization review systems, clinical support systems, and business support applications.
• Promotes the 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.

Requirements

• 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 years.
• Current state of Maryland Registered Nurse license.
• Certification in Utilization Management and/or Care Management highly desired.
• Five years of diversified, progressive experience in acute care and/or other settings within the continuum required.
• Two 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 professionals.
• Strong organizational and time management skills.
• Ability to operate independently and balance multiple priorities.
• Proficiency in electronic medical record review.

Core Values

• Respect: Treats everyone with courtesy, fairness, kindness, and respect for personal dignity and privacy. Listens and responds appropriately to others’ needs, feelings, and capabilities.
• Excellence: Strives for superior performance in every aspect of work. Recognizes and celebrates the accomplishments of others. Meets and/or exceeds customer expectations, actively pursues learning and self-development, and pays attention to detail.
• Accountability: Takes ownership to solve problems, sets a positive professional example, and reports to work regularly and on time.
• Teamwork: Works cooperatively and collaboratively with others for the success of the team. Addresses and resolves conflict positively and seeks out the ideas of others to reach the best solutions.
• Ethical Behavior: Demonstrates honesty, integrity, and good judgment. Respects the cultural, psychosocial, and spiritual needs of patients, families, and coworkers.
• Results: Sets goals and measures outcomes that support organizational goals. Embraces change and improvement, displays flexibility in dealing with new situations or obstacles, and achieves results on time by focusing on priorities.

Pay

Pay Range: $68,281.18 - $110,274.20. Final salary offer will be based on the candidate's qualifications, education, experience, and alignment with organizational needs.