Utilization Review Nurse (Full-Time)

Boston Medical Center; Towson (MD); On-site; 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

Under general supervision, provides consultative support to the 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 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 to identify appropriate medical necessity, length of stay, and level of care based upon evidence based clinical guidelines.

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.

Licensure, Certifications

• Current state of Maryland Registered Nurse license
• Bachelor of Science in Nursing (BSN) Certification in Utilization Management and/or Care Management highly desired.

Experience

• Five (5) years diversified, progressive experience in acute care and/or other settings within the continuum required.
• Two (2) 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 professional
• Strong organizational and time management skills
• Ability to operate independently and balance multiple priorities
• Proficiency in electronic medical record review

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.
• 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 a 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 payer, either via the telephone or in person.
• 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 ancillary, and nursing staffregarding 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 participates in interdisciplinary decisions and care of the patient.
• Consults with interdisciplinary team members to address problems, and makes recommendations to solve problems.
• Assists with discharge planning, by preventing un-necessary hospital utilization, assist in the appropriate return of 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.
• 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.

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 privacy Listens 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 expectations Actively pursues learning and self-development Pays 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 others Takes ownership of problems and does what is needed to solve them Appropriately plans and utilizes required resources for various job duties Reports 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 team Addresses and resolves conflict in a positive way Seeks out the ideas of others to reach the best solutions Acknowledges 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 judgment Respects 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 environment Continuously seeks to improve the quality of products/services Displays flexibility in dealing with new situations or obstacles Achieves results on time by focusing on priorities and manages time efficiently

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.

Situated in scenic Towson, GBMC represents more than just a hospital; it's a legacy of over 60 years in premier healthcare. Our beautiful suburban campus is home to a facility with over 250 beds, 23,000 admissions, and 52,000 emergency room visits each year.

GBMC is currently seeking talented, compassionate employees to support patients of the communities we serve.

GBMC has also been named “best place to work!”

At GBMC Health Partners, we don't just provide comprehensive medical care – we build lasting relationships.

When it comes to the care of our patients, for us, it's personal. Whether you’re a physician leading proactive health strategies, a nurse practitioner providing care, or a medical assistant ensuring seamless operations, your role here is pivotal.

First Provider Group

At Gilchrist, we transcend Traditional hospice care. Every individual's journey is unique, and we pride ourselves on being there, every step of the way. For over three decades, Gilchrist has stood as a pillar of compassion and dedication as Maryland's premier nonprofit provider for serious illness and end-of-life care. We are more than just a hospice; we are a life-affirming promise ensuring every moment is lived to its fullest.

Hospice of Washington County (HWC)

Situated in Hagerstown, MD, HWC, is the only licensed provider for hospice care within Washington County. Our team of committed professionals understands the importance of ensuring that every individual is able to LIVE their life to the fullest. The focus is on caring for the individual, not the cure. Hospice focuses on helping a person live; making the most of each minute, hour, day, week and month they may have during the final season of life. It is about allowing self-determined life closure; individuals remain the decisions makers of how they will spend their precious days, weeks, and months. Hospice care focuses on quality of life, not quantity. We provide hospice care wherever the individual designates as their home. That includes private residence, nursing home, or assisted living facility. Hospice care is available to patients of any age, religion, race, or illness. Hospice care is covered under Medicare, Medicaid, most private insurance plans.

What We Offer:

• Competitive salary and generous paid time off
• Free parking
• Monthly MTA bus pass subsidy-85% paid by GBMC "if applicable"
• Company subsidized onsite fitness and wellness center "if applicable"
• Pre-paid tuition to pursue professional development, additional certifications, and degree programs
• Comprehensive health, dental, and vision coverage 401 (a) and 403 (b) retirement savings plan

Pay Range $68,281.18 - $110,274.20