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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.