REMOTE Utilization Review Nurse - ED - 3 pm - 11 pm

About the position The Utilization Review Nurse position at GBMC is a full-time remote role that requires the nurse to provide consultative support to the admitting teams regarding patient status determinations and the utilization of resources for patients requiring hospital services. This role is crucial in ensuring that patients receive appropriate care while also maintaining cost-effective outcomes. The nurse will work collaboratively with interdisciplinary teams to facilitate appropriate status determinations through the utilization review process, which supports quality patient outcomes. The position involves analyzing clinical information and performing timely initial and concurrent reviews using InterQual screening software. The scheduled hours for this position are from 3 pm to 11:30 pm, and the nurse will need to come onsite monthly for scheduled meetings. In this role, the nurse will be responsible for reviewing electronic medical records during the pre-admission process to determine the appropriate patient status, optimizing correct patient classification, and ensuring timely payer notifications. The nurse will develop initial admission reviews for patients requiring hospital services and provide timely status recommendations to admitting providers in accordance with departmental and clinical guidelines. Additionally, the nurse will maintain a working knowledge of contractual and clinical criteria guidelines, ensuring compliance with all payers who require authorizations and clinical submissions. The role also involves educating physicians and interdisciplinary teams about admission decisions, financial and clinical outcomes, and documentation requirements. The Utilization Review Nurse will be expected to identify system obstacles affecting patient outcomes and consult with interdisciplinary team members to problem-solve. The nurse will demonstrate mastery in InterQual level of care guidelines and possess proficiency in utilization review systems, clinical support systems, and business support applications. The position promotes the use of evidence-based protocols to influence high-quality and cost-effective care, and the nurse will engage in discussions about quality, addressing concerns and promoting continuous improvement. The role may also involve performing concurrent reviews and additional duties as assigned.

Responsibilities

• Provide consultative support to admitting teams regarding patient status determinations and resource utilization. ,
• Analyze clinical information and perform timely initial and concurrent reviews using InterQual screening software. ,
• Review electronic medical records during the pre-admission process to determine appropriate patient status. ,
• Develop initial admission reviews for patients requiring hospital services and provide timely status recommendations to admitting providers. ,
• Maintain knowledge of contractual and clinical criteria guidelines and ensure compliance with payer requirements. ,
• Educate physicians and interdisciplinary teams about admission decisions, financial and clinical outcomes, and documentation requirements. ,
• Identify system obstacles affecting patient outcomes and consult with interdisciplinary team members to problem-solve. ,
• Demonstrate mastery in InterQual level of care guidelines and proficiency in utilization review systems. ,
• Promote the use of evidence-based protocols to influence high-quality and cost-effective care. ,
• Engage in discussions about quality and promote continuous improvement.

Requirements

• Bachelor of Science in Nursing (BSN) or Associate of Science in Nursing with enrollment in a BSN program expected to graduate within three years. ,
• Five years of diversified, progressive experience in acute care or other settings within the continuum. ,
• Two years of Utilization Management experience, including utilization review processes and discharge planning preferred. ,
• Advanced knowledge of InterQual and/or MCG admission criteria. ,
• Knowledge of healthcare regulatory standards. ,
• Advanced skill in using computer software and electronic medical record review. ,
• Strong analytical and problem-solving skills. ,
• Ability to work independently and resolve complex problems under pressure. Nice-to-haves
• Certification in Utilization Management and/or Care Management highly desired.

Benefits

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