Jobs search

JOB DETAILS

Utilization Review RN - As Needed - Days

GBMC Healthcare • Part-time • Towson, Maryland, United States • 3m ago

Under general supervision, utilize clinical knowledge and critical thinking skills to provide oversight of appropriate admission status and utilization of hospital resources facilitating quality, cost-effective patient outcomes. Works collaboratively with interdisciplinary staff internal and external to the organization ensuring maximum reimbursement for the hospital through the utilization review process. Active participation and attendance in daily multidisciplinary rounds. Responsible for analyzing clinical information and performing timely concurrent and retrospective 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 Advanced Practitioner licensure

Licensures/Certifications:

• Current state of Maryland Registered Nurse, Physician Assistant, or Nurse Practitioner license

• Certification in Utilization Management and/or Care Management highly desired.

Experience:

Seven (7) years diversified, progressive experience in acute care and/or other settings within the continuum required.

Two (2) years of Case Management which includes Utilization Review, Discharge Planning and working with Re-Admission Initiatives preferred.

Skills:

• Broad knowledge of medical treatment practices

• Knowledge of healthcare regulatory agency standards for health care organizations.

• Ability to operate independently and to balance multiple priorities.

• Strong interpersonal, and influencing skills necessary to interact effectively with physicians, payers, regulatory agencies, staff, and other health professionals

• Knowledge of InterQual and/or Milliman criteria

• Skill in using computer software programs

• Advanced skill in oral and written communication

• Advanced skill in critical thinking

• Ability to resolve complex problems

• Ability to remain calm under pressure and intense time constraints

• Ability to assess discharge needs for patients

Principal Duties and Responsibilities:

• Assesses patients within a defined caseload to identify clinical status, needs, issues, financial resources, and care goals; demonstrates knowledge of reimbursement mechanisms. Considers patient’s financial resources for meeting healthcare needs (insurance reimbursement, managed care plans, entitlement programs, and personal resources).

• Reviews the appropriateness of admission and continued stay criteria for a defined group of patients and either develops a concurrent stay and/or discharge plan of care in accordance with payer and clinical guidelines.

• Maintains a working knowledge of the contractual requirements and clinical criteria guidelines of payers. 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

• Promotes use of evidence based protocols to influence high quality and cost effective care.

• Participates in education of physician, ancillary, and nursing staff regarding utilization review, financial and clinical outcomes, as well as documentation requirements/standards.

• Maintain current knowledge on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians.

• Identifies service specific procedures and system obstacles that affect patient outcomes. Consults with health team members to address problems, and makes recommendations to resolve them. Collaborates with social work on complex discharge planning needs.

• Keeps management informed and up to date on clinically complex, emotionally intense, politically sensitive, and financially weighty cases, offering possible solutions through discussion and feedback.

All roles must demonstrate GBMC 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

COVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.

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.

Related Jobs

Clinical Review Nurse

Johns Hopkins Medicine • Part-time • Baltimore, MD, US • 2m ago

RN Utilization Review

Johns Hopkins Care at Home (JHCH) is a leading provider of home care services, committed to delivering high-quality, patient-centered care. We are currently seeking a dedicated and experienced Clinical Review Nurse... more

2m ago

VIEW JOB

Registered Nurse - RN - JHHS Emergency Room

Johns Hopkins Medicine • Full-time • Baltimore, MD, US • 12h ago

RN ER

NOW HIRING Experienced & New Grad RNs in the Emergency Room Opportunities in Baltimore, Columbia, DC, and Tampa! Whether you prefer to work in an academic teaching hospital, community hospital, full-time,... more

12h ago

VIEW JOB

RN 2 - Emergency Department - Rotating Shifts

Johns Hopkins Medicine • Full-time • Baltimore, MD, US • 12h ago

RN ER

The Johns Hopkins Bayview Medical Center's Emergency Department is a Level II Trauma Center, and proudly serves as the region's one-and-only Burn Center! Shifts: Weekend Night Shifts Qualifications: •... more

12h ago

VIEW JOB

Assistant Director of Nursing (ADON)

Autumn Lake Healthcare at Pikesville • Full-time • Pikesville, MD, US • 18h ago

Join our wonderful team as an Assistant Director of Nursing (ADON) today! Autumn Lake Healthcare at Pikesville is an exceptional team-oriented company hiring for Assistant Director of Nursi... more

18h ago

VIEW JOB

RN Unit Manager - $10,000 Sign-On Bonus

FutureCare • Full-time • Randallstown, MD, US • 1d ago

Overview At FutureCare our RN Unit Managers are highly regarded as health care providers that lead a dedicated nursing team. They have a positive impact on staff and residents and set the standard of excellence for o... more

1d ago

VIEW JOB

Intrastaff RN PRN

Johns Hopkins Medicine • Per Diem • Baltimore, MD, US • 1d ago

Johns Hopkins Intrastaff is the internal staffing agency for the Johns Hopkins Health System and partner hospitals, providing temporary support to a variety of the Johns Hopkins locations. Our employees are the strengt... more

1d ago

VIEW JOB

JHH IMC/ICU Float Pool RN (AM & PM Contracts Available)

Johns Hopkins Medicine • Full-time • Baltimore, MD, US • 1d ago

RN ICU

1d ago

VIEW JOB

Registered Nurse (RN) Neuro Interventional Radiology

MedStar Health • Full-time • Baltimore, MD, USA • 1d ago

General Summary of Position Unit Highlights Stroke Certified Center and Elite Plus Gold, Stroke Award Honor Role 1:1 Patient to nurse ratio Four 9-hour shifts Monday-Friday 7:00am-4:30pm with 10 on-c... more

1d ago

VIEW JOB

Registered Nurse (RN) Medical Surgical Renal

MedStar Health • Full-time • Baltimore, MD, USA • 1d ago

RN Med-Surg

General Summary of Position Unit Highlights Full time and Per Diem night shift openings! Join our dedicated team at MedStar Health Franklin Square Medical Center, where you'll make a real impact on... more

1d ago

VIEW JOB

Registered Nurse (RN) - Cardiovascular Thoracic OR

Johns Hopkins Medicine • Full-time • Baltimore, MD, US • 1d ago

Full-time, 10 hour Day/Evening Rotation The Johns Hopkins Hospital has been at the forefront of discovery, innovation, and medical advances for over 125 years. Our reputation for excellence has earned us... more

1d ago

VIEW JOB