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Sr Utilization Review RN - Inpatient

Company: Johns Hopkins Health Care
Location: Hanover
Posted on: October 19, 2020

Job Description:

Johns Hopkins HealthCare (JHHC) is the managed care and health services business of Johns Hopkins Medicine, one of the premier health delivery, academic, and research institutions in the United States. JHHC is a $2.5B business serving over 400,000 lives with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHC has become a leader in provider-sponsored health plans and is poised for future growth.

Many organizations talk about transforming the future of healthcare, Johns Hopkins HealthCare is actually doing it. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for the members and communities we serve. If you are interested in improving how healthcare is delivered, join the JHHC team.

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.

  • Work requires incumbent to be a graduate of an accredited school of nursing; BSN 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.

      • Current Registered Nurse licensure in the state of Maryland
      • Certification in Case Management (CCM) or Utilization Management preferred
      • Minimum of three years of nursing experience which includes a minimum of three years in an acute care hospital setting
      • Minimum two years management experience, preferably in the managed care environment.


        • 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.

          Senior Utilization Review Nurse -

          Excellent computer skills working with a variety of databases and claims systems.

          Ability to work in a dynamic team-oriented environment and demonstrate positive relationship building.

          Ability to affect change.

          Ability to perform critical analysis, plan and organize effectively.

          Ability to effectively orient and train new staff.

          Ability to make effective case presentations, as required.

          Serves as clinical expert in the development and evaluation of Utilization Management.D. Required Licensure, Certification, Etc.:

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

          Senior Utilization Review Nurse -

          Certification in Healthcare Management/Managed Care or Utilization Management preferred.E. Work Experience:

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

          Senior Utilization Review Nurse -

          Minimum five years clinical practice. Minimum two (2) years utilization management experience, one of which must be in a managed care environment.F. Machines, Tools, Equipment:

          Must be able to operate general office and communications equipment.


          A. Budget Responsibility:

          Effectively uses resources.

          Reviews/interprets patient population specific financial reports.

          Maintains budgeted caseload.

          Effectively uses resources within control.B. Authority/Decision Making Level:

          Makes decisions regarding work processes based on established guidelines and protocols.

          Prioritizes and organizes work to meet changing priorities.

          Works independently with limited supervision.C. Supervisory Responsibility:

          May assign work to support staff.

          Senior Utilization Review Nurse -

          May lead team meetings. May provide guidance and direction to URN in the absence of the Program Manager or Director.Problem Solving:

          Uses specific body of knowledge and defined policies and procedures to coordinate patient care across the continuum to improve patient outcomes. Identifies and acts upon impending changes in patient condition. Using nursing analysis, presents patient/member clinical cases to Medical Director with recommendation for possible next steps, or payment decisions as it relates to that clinical case discussion. Coordinates discharge planning with Senior UN or Management.

          Senior Utilization Review Nurse -

          Identifies and analyzes staff/patient/system issues that impact the plan of care. Understands and uses principles of negotiation. Makes independent nursing decisions as it relates to predicted treatment plans and stable clinical circumstances regarding authorization for payment, or discharge planning decisions. Offers creative options for discharge planning and transfer situations as they relate to clinical care.Information Management:

          Must be able to perform basic data entry and understand patient data reports.

          Senior Utilization Review Nurse -

          Analyzes complex data sets to improve patient financial/quality care outcomes.Working Conditions:

          Work requires concentration and constant attention to accuracy and detail for extended periods of time. Work may require cross-training and coverage of colleagues.

          Work requires daily use of a computer. Work requires regularly handling multiple patient cases involving a variety of providers, situations, deadlines, and multiple priorities. Hospital inpatient acute and sub-acute facility on site visits and discussions, as appropriate. Work requires attendance at company office and off-site meetings. Corporate Teleworking agreements policies must be followed, as appropriate.

Keywords: Johns Hopkins Health Care, Baltimore , Sr Utilization Review RN - Inpatient, Healthcare , Hanover, Maryland

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