Utilization Review Nurse: Care Management & Payer Liaison

Boston Medical Center; Towson (MD); Hybrid; USD 68,000 - 110,000; Full time

Benefits offered by this job

Competitive salary and generous PTO

Free parking

Monthly bus pass subsidy

Onsite fitness and wellness center

Tuition assistance and development

Health, dental, and vision coverage

Job summary

GBMC HealthCare in Towson, MD, is seeking an experienced Utilization Management Nurse to support admitting teams in determining patient status and ensuring appropriate use of resources. The role requires robust clinical judgment, collaboration with physicians and payers, and adherence to evidence-based processes.

The position involves reviewing clinical information with InterQual/MCG criteria, guiding discharge planning, and optimizing care and cost outcomes while maintaining regulatory

Qualifications

• BSN or enrollment in BSN program within three years.
• Maryland RN license is required.
• BSN Utilization Management certification desired.

Responsibilities

• Reviews EMR to determine patient status and payer notifications.
• Assesses admission and continued stay criteria for defined patients.
• Develops initial admission reviews and concurrent discharge plans.
• Coordinates services with managed care and payers.
• Escalates complex cases to leadership with possible solutions.
• Supports discharge planning and post-acute care transitions.
• Keeps updated on regulatory changes and guidelines.
• Advises physicians using InterQual level-of-care criteria.

Skills

InterQual knowledge

MCG criteria

Utilization review

Discharge planning

Healthcare regulations

Clinical analysis

EMR review

Communication skills

Problem solving

Time management

Education

BSN

ASN in progress

Tools

InterQual

MCG

Electronic Medical Records

Job description

GBMC HealthCare in Towson, MD, is seeking an experienced Utilization Management Nurse to support admitting teams in determining patient status and ensuring appropriate use of resources. The role requires robust clinical judgment, collaboration with physicians and payers, and adherence to evidence-based processes.

The position involves reviewing clinical information with InterQual/MCG criteria, guiding discharge planning, and optimizing care and cost outcomes while maintaining regulatory