[Hiring] Utilization Review Nurse @Johns Hopkins Medical Management Corporation

Role Description

This role involves facilitating and coordinating programs that may include hospital inpatients, outpatients, families, community, and employees of both the hospital and the university by providing evidence-based care based on the nursing process, policies, procedures, and protocols of the Johns Hopkins Hospital.

• Providing direction to/management of other team members to promote quality, safety, and excellence in care.
• Working collaboratively with and providing leadership for a multidisciplinary health care team to support program initiatives that support quality, safety, and excellence in care.
• Participating in promoting and identifying quality improvement initiatives (clinical, financial, operational) that support, protect, and promote area of specialty.
• Initiating and participating in the research activities relevant to the specialty area.
• Implementing initiatives in the area of specialty as directed by nursing and medical leadership.
• Fostering a clinical environment of service excellence.

Duties include the day-to-day management of health confined plan members in acute care and/or rehabilitative facilities. The Utilization Nurse (UN) actively monitors the appropriateness of care received by plan members in a variety of settings, such as acute hospitals, sub-acute hospitals, and acute rehabilitation facilities.

• The Utilization Nurse applies member benefits and medical criteria to determine authorization of services in coordination with the Medical Directors.
• The Utilization Nurse proactively initiates discharge planning for members, including identification of post-discharge needs and coordination of post-discharge referrals/services.
• The UN communicates verbally and in writing authorization and/or denial of covered services with providers, facilities, and members.
• The UN is a member of the administrative and clinical teams in the area of assignment.
• Clinical knowledge is maintained and updated, and UN must maintain acceptable documentation and quality standards.

Qualifications

• Active RN License
• 5 years RN experience
• Current UR experience
• EPIC and referral platforms such as NaviHealth or AllScripts
• Knowledge and use of Proficiency using InterQual and/or Milliman criteria software systems
• Managed care experience in utilization review for at least 1 year preferred
• BLS certification

Requirements

• Excellent verbal and written communication skills to effectively interact and work correctly with enrollees, Physicians facility staff, and management staff.
• Excellent interpersonal skills and an attitude to effectively project a positive image of our Managed Care Program.
• Computer skills working with a variety of applications and online systems.
• Knowledge of Enterprise and utilizing various criteria sets, i.e., InterQual.
• Ability to negotiate and resolve conflicts with external customers.

Benefits

• $55/hr
• Shift: Mon – Fri, 8:00am-5:00pm EST
• Work Location- REMOTE
• No call, holiday, or weekend
• There is no direct patient care; this is a medical review position only.