Intrastaff

Utilization Review Nurse

US-MD-Baltimore
Job ID
2017-1170
Johns Hopkins Hospital
Category
Clinical
Type
Temporary Full Time

Overview

Johns Hopkins Intrastaff is the internal staffing agency for the Johns Hopkins Health System and partner hospitals, providing temporary support to a variety of the Johns Hopkins locations. Our employees are the strength of our service.  Intrastaff is unique because it's one of the very few agencies where a person has the benefit of being a temporary employee and also feels like a member of a large organization. Working at Hopkins means joining a culturally diverse team that includes some of the best nurses, physicians and allied health professionals in the world. Directly or indirectly, you'll have exposure to cutting-edge technology and groundbreaking medical research.

 

The Utilization Review Nurse performs utilization review of all patients presenting for hospitalization to assist in identifying patients appropriate for admission to inpatient, observation, or other patient care status. We conduct continued stay review evaluating the medical necessity, appropriateness and efficient use of health care services of all hospitalizations, inpatient or outpatient. The Utilization Review Nurse collaborates with physicians, the health care team and care coordinator to optimally certify the level of care and facilitate the patient’s movement through the continuum of care as appropriate.

Responsibilities

  • Demonstrates expertise in the application of InterQual and Milliman criteria.
  • Reviews of clinical data for ED admits,
  • Manages all direct admits, clarifying level of care orders and performing Milliman/InterQual screening as appropriate. Acquires additional information if necessary to assist in level of care determination.
  • Insures operative procedure performed is the operative procedure prior-authorized with the third party payor and communicates any variance.
  • Performing clinical reviews of all inbound transfers for appropriateness.
  • Monitors use of healthcare resources. Communicates with physicians to assure patient receives diagnostics/evaluations in the proper setting, i.e. inpatient vs outpatient
  • Maintains current knowledge of CMS (Medicare) rules and regulations.
  • Communicates openly with third party payors and works collaboratively with them to avoid concurrent denials.
  • Collaborates with the care coordinator to ensure appropriate level of care,
  • Actively participates in the multidisciplinary team meetings
  • Identifies and documents delays in service
  • Serves as an expert resource to physicians and healthcare staff in the application of InterQual criteria and the use of evidence based practices.
  • Conducts initial (admission) reviews at the time of presentation, or within 24 hours, if patient presents during uncovered hours.
  • Conducts concurrent review per department policy (every three days for Medicare unless the patient condition changes), and as private payor dictates.
  • Conducts observation reviews daily.
  • Follows department policy regarding escalation of utilization issues to the Physician Advisor or his/her designee.

Qualifications

  

RN Maryland license

 

2 years of recent related experience

 

 

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

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