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Outpatient Utilization Review Nurse
4 months ago
Johns Hopkins Health Plans is a leader in provider-sponsored health plans. If you are interested in improving how healthcare is delivered, and have a passion to be at the forefront of change, JHHP is the place to call home. YOU belong here.
What awaits you:
- Work-life balance - This is a remote role
- Medical, Dental, and Vision Insurance.
- 403B Savings Plan w/employer contribution.
- Paid Time off & Paid holidays.
- Employee and Dependent Tuition assistance benefits.
- Health and wellness programs and MORE
Who you are:
As an Outpatient Utilization Review Registered Nurse for Johns Hopkins Health Plans, you have the opportunity to use your clinical, managed care, utilization review, and verbal/written communication skills to make a difference in our members’ lives. Your in-depth knowledge of the appropriate levels of care make you a valuable resource to our members when they are in need.
What you’ll do:
- Review for appropriateness of care received by plan members in a variety of settings
- Evaluate member benefits and medical criteria to determine authorization of services
- Communicating authorization and/or denial of covered services with all parties involved
- Utilize various criteria sources such as COMAR, InterQual, Tricare Policy Manual, and/or CMS guidelines to make determinations.
- Review requests for services, procedures, and equipment that require prior authorization
What you’ll bring:
- 3+ years’ experience as an acute care RN
- 1+ years’ experience in Utilization within a Managed Care Organization (MCO).
- Understanding of managed care delivery systems and utilization management
- Excellent verbal/written communication skills to effectively interact and work collectively with enrollees, physicians, facility staff and management staff
- Knowledge and expertise in utilizing various criteria sets (i.e. InterQual/MCG)
- Ability to negotiate and resolve conflicts with external customers.
- Unencumbered Registered Nurse (RN) license in Maryland (or Compact state)
- BSN is preferred
This is a full-time position. The hours are Monday - Friday, and the core business hours are 8:00 AM - 5:00 PM
Who we are:
Johns Hopkins Health Plans (JHHP) is the managed care and health services business of Johns Hopkins Medicine. JHHP is a $3B business serving over 500,000 active members with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHP is a leader in provider-sponsored health plans and is poised for future growth.
Many organizations talk about transforming the future of healthcare, at Johns Hopkins Health Plans, we are setting the pace for change within the healthcare industry. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for our members and the communities we serve.
Johns Hopkins Health System and its affiliates are drug-free workplace employers.
