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 of services to designated populations. Responsible for the day to day direction of Utilization Nurses. Responsible for maintaining adequate staffing, and ensures processes are followed according to UM policy and procedures. Focused on on-site and concurrent review clinical management and care coordination. Prepares monthly and quarterly reports to measure days variances, conduct root cause analysis and monitors, measures and trends re-admission levels.
Bachelor’s degree in Nursing or related field required. Master’s degree in Nursing or related health care field preferred.
Knowledge of health care and managed care delivery systems. This includes standards of medical practice; insurance benefit structures and related legal/ medical issues; and utilization management and quality improvement processes.
Work requires a high level of interpersonal skills to effectively interact and affect change with all levels of staff , providers, and outside business related associates.
Work requires the ability to work independently, to assess situations and respond appropriately, and the ability to initiate and implement policy and procedures. Must be willing to accept change.
Work requires excellent communication and writing skills. Work requires the ability to facilitate and promote public relations to the community and civic groups in addition to excellent communication skills with all levels of staff, providers, and outside business related associates.
Work requires a high level of interpersonal skills and attitude to effectively project a positive image of managed care programs by being professional, courteous, helpful and friendly in relationships with all levels of staff, providers, and external business related associates.
Work requires experience with exempt and nonexempt staff. It requires an understanding of work process flows from Intake through final completion of the Medical Review request.
D. Required Licensure, Certification, Etc.:
Current Registered Nurse licensure in the state of Maryland
Certification in Case Management (CCM) or Utilization Management preferred
E. Work Experience:
Minimum of eight years of nursing experience which includes a minimum of three years in a managed care environment (case management or utilization management).
Minimum two years management experience, preferably in the managed care environment.
Understands the role of Intake, call center functions, and benefits
F. Machines, Tools, Equipment:
Must be able to operate computer, general office, and communication equipment.
A. Budget Responsibility:
Effectively uses resources within control. Monitor department/cost center budget. Works with Utilization Management Director on budgetary matters.
B. Authority/Decision Making Level:
Makes decision about staffing and office requests. Makes decisions regarding work processes based on established guidelines. Prioritizes the workload of the Intake Services and Outpatient Medical Review staff. Develops reports and documentation materials. Works independently with limited supervision.
C. Supervisory Responsibility:
Manages Intake Services and Outpatient Medical Review staff and has the responsibility for hiring, firing, performance management and results of the area. Responsible for overall departmental training and documentation for all staff. Provides guidance and direction to other departmental management and staff. Responsible for adequate coverage for Intake Services and Outpatient Medical Review area.
Seeks opportunities to develop the staff, and encourages participation in performance improvement activities
Manages work flow from Intake Services though Outpatient Medical Review maximizing quality and efficiency.
Performs critical thinking as it relates to Intake Services and Outpatient Medical Review. Utilizes defined policies and procedures to ensure consistent application of care management criteria.
Responsible for all quality related activities including but not limited to case audits for all staff & Inter Rater –Reliability (IRR) for clinical staff.
Must be able to perform data entry and understand patient data reports, utilizationreports, and measure and assess outcomes.
Works in office environment.
Work is sedentary in nature, however, some standing, stooping, bending and walking is requires. The position requires keyboard activity, pulling, filing, and duplicating.
Requires local travel to off-site meetings.