Inpatient Medical Review RN

Johns Hopkins Healthcare   •  

Glen Burnie, MD

Industry: Healthcare

  •  

5 - 7 years

Posted 149 days ago

This job is no longer available.

Johns Hopkins employs more than 20,000 people annually across our health system. When joining Johns Hopkins, you became 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. Great careers continually advance here.

Responsible for 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, acute hospital, sub-acute hospital, and acute rehabilitation facility. The Utilization Nurse applies member benefit and medical criteria to determine authorization of services in coordination with the Medical Director. The Utilization Nurse proactively initiates discharge planning for of 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 administrative and clinical teams in the area of assignment. Clinical knowledge is maintained and updated and UN must maintain acceptable documentation and quality standards.

Requirements:

  1. Education:

Registered Nurse (RN) with active unrestricted license in the State of MD. BSN preferred.

B. Knowledge:

Knowledge of health care and managed care delivery systems.

Standards of medical practice.

Utilization management.

Knowledge of Community resources.

Senior Utilization Nurse:

Proficiency using InterQual and/or Milliman criteria.

Ability to analyze complex data.

C. Skills:

Excellent verbal/written communication skills to effectively interact and work collectively with enrollees, physicians, facility staff and management staff in English.

Work requires excellent interpersonal skills and attitude to effectively project a positive image of managed care programs.

Computer skills working with a variety of applications and online systems.

Knowledge and expertise in utilizing various criteria sets, for example InterQual.

Ability to negotiate and resolve conflicts with external customers.

D. Required Licensure, Certification, Etc.:

Registered Nurse (RN) with active unrestricted license in the State of MD. BSN preferred.

E. Work Experience:

Minimum of five (3) years of acute care nursing experience. Participation in quality improvement activities. Managed care experience in utilization review of at least one year required.

F. Machines, Tools, Equipment:

Must be able to operate general office and communications equipment.

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