Johns Hopkins Health System employs more than 20,000 people annually. Upon joining Johns Hopkins Health System, you become part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. If you share in our vision, mission and values and also have exceptional customer service and technical skills, we invite you to join those who are leaders and innovators in the healthcare field.
Responsible for the Utilization Management (UM) functions for Health Plan membership. This position provides strategic direction and oversight of the day-today operations of the corporate utilization management function(s), ensuring that activities are appropriately aligned with mission objectives and strategic imperatives, as well as the mission and values of the company, while ensuring patient safety. This position provides day-to-day direction to UM staff including maintenance of adequate staffing, assurance of adequate staff training and ongoing education, and direction of the operations of the referral management, telephonic and onsite utilization management activities, and prior authorization functions inclusive of the timely notification of high quality decisions. Provides clinical support and communicates with departmental and plan administrative staff to facilitate daily department functions, in accordance with government and contractual guidelines and the mission, philosophy and objectives of the health plan.
Directs and develops the UM program annually and ensures the success of UM functions through medical review and prior authorization, behavioral health management, clinical intake, and inpatient and outpatient nurse review. Directs and develops specialty programs to support and ensure success of the UM program, inclusive of innovative programs that emphasize and utilize hospital collaborative work relationships, and internal and external partnerships; ensures compliance and administration of utilization policies through cost effective management of UM operations. Director will serve on various Committees inclusive of Co-Chair of the QI Workgroup and UM Close Committees, and will serve as liaison to the participating hospitals. Develops, secures approval and monitors and reports on area operating budget; forecasts spending levels, staffing requirements and resource needs for area.
Requires a Master’s degree in Nursing or related health care field. Candidates with a Bachelor’s degree and equivalent work experience may be considered.
Requires a thorough solid knowledge of health care and managed care delivery systems. This includes standards of medical practice; insurance benefit structures and related legal/ clinical issues; and utilization management and quality improvement processes.
Requires an expert level of leadership, teamwork, and interpersonal skills to effectively interact, communicate, and affect change with all levels of staff, and outside business related associates.
Requires the ability to work independently, to assess situations and respond appropriately, and the ability to initiate and implement policy and procedure. Must be willing to accept change.
Requires excellent professional communication and writing skills. Work requires the ability to facilitate and promote public relations to the community and civic and professional groups
Requires to the ability to effectively project a positive image of managed care programs by being professional, courteous, helpful and knowledgeable in relationships with all levels of staff, and external business related associates.
Exceptional clinical decision making and expert problems solving.
D. Required Licensure, Certification, Etc.:
Current registered nurse licensure in the state of Maryland required; CCM (certified case manager), CPUM (certified professional in utilization management), or other applicable certification preferred.
E. Work Experience:
Minimum of ten years of nursing experience required.
Minimum of five years in a managed care environment (case management or utilization management) required.
Requires five years of progressive management experience, preferably in the managed care environment.
F. Machines, Tools, Equipment:
Must be able to operate computer, general office and communication equipment.
A. Budget Responsibility:
Develops, monitors and reports on program operating budgets for departmental cost centers,
B. Authority/Decision Making Level:
Makes decision about staffing and office requests. Makes decisions regarding work processes based on established guidelines, with continuous quality improvement methods applied. Prioritizes the workload of the utilization management staff. Develops reports and documentation materials. Expert Utilization Management resource for the Company. Directs nursing clinical decision making. Works independently with limited supervision.
C. Supervisory Responsibility:
Manages utilization management and admin support staff: has the responsibility for hiring, firing, performance management and results.
Perform critical thinking as it relates to medical management activities. Utilizes defined policies and procedures to ensure consistent application of medical/utilization management criteria. Uses problem solving and quality analysis.
Must be able to utilize multiple software programs and understand patient data reports, finance, and utilization reports. Analytical thinking and data analytics with barrier analysis, corrective action, initiative planning, intervention and/or program/policy change, as appropriate.
Works in office environment. Work is sedentary in nature, however, some standing, stooping, bending and walking is required. The position requires keyboard activity, and some filing
Requires local travel to off-site meetings or professional gatherings. Some long distance travel may be necessary for professional training and development.
Requisition #: 176187