Utilization Review Nurse Registered Nurse CI

Main Purpose of Job

This position is responsible for conducting reviews on admissions, continued stays, and readmissions, as well as managing the denial process. This position is vital to addressing the Maryland Department of Health (MDH) waitlist by identifying patients who no longer meet medical necessity criteria for inpatient care. These reviews are conducted independently of treatment teams to provide objective feedback to hospitals regarding patient progress. This position also manages the appeal process, working with the Physician Advisor when patients do not meet medical necessity criteria. Cases are presented to the Utilization Review to recommend the committee to determine if a second Physician Advisor review is required. This is a hybrid position that allows for teleworking. This position provides reports that identify opportunities to improve care through medical record reviews. These improvements may include the adequacy of documentation regarding patient progress, missing or insufficient records, the absence of required assessments, and the overall quality of treatment.

Minimum Qualifications

• Education: Determined by the Maryland State Board of Nursing under the licensing requirements for Registered Nurses.
• Experience: None.

Desired or Preferred Qualifications

• Experience using Google Suites (especially Google Sheets) to complete NRI statistics and maintain utilization review files and the UR database
• Experience in Risk Management

Licenses, Registrations, and Certifications

• Candidates must possess a current license as a Registered Nurse from the Maryland State Board of Nursing, 4140 Patterson Avenue, Baltimore, Maryland 21215 or possess a current multi-state license in party states that candidates have declared as primary states of residence.
• Employees may be assigned duties which require the operation of a motor vehicle; such employees will be required to possess a motor vehicle operator's license valid in the State of Maryland.
• Employees may be required to successfully complete and maintain current certification of cardiopulmonary resuscitation training.

Special Requirements

• Employees are subject to call-in and will be required to provide the facility with a phone number at which they can be reached.
• Employees are subject to substance abuse testing in accordance with Code of Maryland Regulations 17.04.09, Testing for Illegal Use of Drugs.

Selection Process

• Applicants who meet the minimum (and selective) qualifications will be included in further evaluation. The evaluation may be a rating of your application based on your education, training and experience as they relate to the requirements of the position.
• It is essential that you provide complete and accurate information on your application. Please report all related education, experience, dates and hours of work. Clearly indicate your college degree and major on your application, if applicable.
• For education obtained outside the U.S., any job offer will be contingent on the candidate providing an evaluation for equivalency by a foreign credential evaluation service prior to starting employment (and may be requested prior to interview).
• Complete applications must be submitted by the closing date. Information submitted after this date will not be added. Incorrect application forms will not be accepted. Resumes will not be accepted in lieu of a completed application.
• Candidates may remain on the certified eligible list for a period of at least one year. The resulting certified eligible list for this recruitment may be used for similar positions in this or other State agencies.