Emergency Department Utilization Review Registered Nurse, 9:00AM-5:30PM, with some holiday and weekend on-call coverage

Greater Baltimore Medical Center•Towson, MD

54d

About The Position

Under general supervision, provides consultative support to the admitting teams concerning patient status determinations and utilization of resources for patients requiring hospital services. Works collaboratively with interdisciplinary teams 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.

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 (3) years.
Five (5) years diversified, progressive experience in acute care and/or other settings within the continuum required.
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
Strong analytical and problem solving skills
Strong interpersonal communication skills
Strong organizational and time management skills
Proficiency in electronic medical record review
Current state of Maryland Registered Nurse license
Bachelor of Science in Nursing (BSN) OR documentation of current enrollment in BSN program with expected graduation within three years of hire
Ability to sit, stand, stoop, and bend.
Maintain current licensure

Nice To Haves

Two (2) years of Utilization Management experience which includes utilization review processes and discharge planning preferred.
Certification in Utilization Management and/or Care Management highly desired.

Responsibilities

Reviews available electronic medical records during the pre-admission process to determine appropriate patient status, optimizing correct patient classification and corresponding payer notifications.
Develops initial admission reviews for patients requiring hospital services and provides timely status recommendations to admitting providers in accordance with departmental and clinical guidelines.
Maintains a working knowledge of contractual and clinical criteria guidelines. 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 regarding 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 consults with interdisciplinary team members to problem solve.
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.