Utilization Review Registered Nurse, Days/Weekends/Holidays

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

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

• 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

• 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 problem solve.
• 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.

• Treats others with fairness, kindness, and respect for personal dignity and privacy

• Listens and responds appropriately to others’ needs, feelings, and capabilities

• Meets and/or exceeds customer expectations
• Actively pursues learning and self-development
• Pays attention to detail; follows through

• 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

• 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

• Demonstrates honesty, integrity and good judgment
• Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers

• 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

$64,675.52 - $104,451.06