REMOTE Utilization Review Nurse - ED - 10 am - 6 pm, 11 am - 7 pm OR 12 pm - 8 pm

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. GBMC is currently hiring a skilled Utilization Review Nurse for a full time REMOTE position. The scheduled hours will be from 3 pm - 11:30 pm. Must be local, will need to come onsite monthly for scheduled meetings.

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. 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