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.
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