Concurrent Review Nurse

Maryland Care Management Inc•Linthicum, MD

About The Position

Summary/Position Objectives: The Utilization Management (UM) Nurse is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services provided to members. Utilizing evidence-based guidelines, regulatory requirements, and health plan criteria, the UM Nurse conducts clinical reviews to determine the appropriate level of care, facilitate authorizations, and promote optimal outcomes. Discharge planning responsibilities begin at the time of admission and are integrated into the overall care coordination process. The UM Nurse collaborates with providers, care managers, and interdisciplinary teams to ensure timely transitions of care and to prevent unnecessary readmissions. This role requires critical thinking, strong clinical judgment, and effective communication to support member-centered, cost-effective care. About Maryland Care Management, Inc. (MCMI) Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care's (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD's largest Medicaid-managed care organizations. Why join us? MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans. Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed. We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members' lives.

Requirements

Demonstrated written and verbal communication skills to include presentations and training before small and large groups.
Strong problem solving, organizational skills and time management skills with the ability to work in a fast-paced environment.
The ability to successfully utilize Microsoft Office suite and common computer and office hardware is necessary.
Must have own reliable transportation with appropriate insurance.
Must be able to work independently with minimal supervision.
Registered Nurse in Maryland
Requires three (3) years clinical/hospital nursing experience, such as ICU, medical/surgical, OB/maternity, etc.
Minimum of one (1) year experience in Managed Care and/or three (3) years experience in UR/UM Concurrent Review experience.

Nice To Haves

BSN preferred

Responsibilities

Conducts concurrent reviews of facility medical records to evaluate care appropriateness and abstracts relevant clinical data.
Assesses level of care, care setting, and anticipated length of stay
Collaborates with the Medical Director to support utilization review decisions.
Maintains ongoing communication with facility UM/CM departments.
Discharge planning initiated at admission and involves ongoing coordination with hospital case managers, discharge planners, and facility staff to ensure a safe and timely transition to the next appropriate level of care.
Identifies barriers to discharge and works proactively to resolve issues that may delay transition of care.
Maintains accurate and timely documentation of all discharge planning activities in accordance with organizational policies.
Participates in internal and external interdisciplinary rounds to advocate for member-centered discharge planning.
Collects and reports data related to quality of care findings and utilization metrics.
Identifies and refers members to case management, disease management, UM Social Work and other support programs.
Adheres to all departmental Utilization Management (UM) policies, procedures, and desktop guidelines to ensure compliance and consistency.
Directs cases of potential over/under utilization for Medical Director review.
Assists with orientation of new staff members.