Director of Utilization Management

Job Summary

Reports directly to the JHH VP of Care Coordination/Utilization Management and indirectly to the JHBMC Senior Director of Care Management and is responsible for the coordination, management and success of The Johns Hopkins Hospital and The Johns Hopkins Bayview Medical Center Utilization Management programs. The Director develops and implements UM plans for both facilities in accordance with the mission and strategic goals, federal and state law and regulations, payor requirements and accreditation standards. The Director collaborates with clinical staff and payers to ensure medically appropriate and cost-effective care, through the application of nationally recognized utilization criteria. The Director collaborates with the Senior Physician Advisor and Physician Advisors to analyze trends and take appropriate actions to reduce risk to both organizations. The Director oversees and manages departmental operations for both facilities to assure the consistent and appropriate performance of prospective, concurrent and retrospective reviews. The Director collects, analyzes and reports on data related to the utilization of medical services and resources and prioritizes performance improvement initiatives based on data analysis. The Director identifies and actively oversees performance measures and outcomes for presentation at the Utilization Review Committee for both facilities. The Director provides leadership and strategic direction to assure professional responsibility, accountability and competency in the processes of utilization management. The Director is responsible for building effective relationships across all internal departments, the Health System, relevant outside insurance companies, and outside healthcare networks. This position requires a candidate with a significant background in utilization management and broad experience with third party practice standards, State and Federal regulations, and the formal denial/appeal process.

Qualifications

Completion of an accredited Registered Nursing Program required. Bachelor’s degree in Nursing, Healthcare Administration or Business Administration. Master’s degree preferred.

Licensed in the State of Maryland as a Registered Nurse (RN) required

Requires demonstrated experience in utilization review and appeals acquired through 10 or more years of progressively-responsible experience such as:

• 10+ years clinical experience as a staff nurse, including 8 or more years clinical experience in an academic medical center with critical care experience required
• 5+ years of experience in a managed care or an insurance company’s utilization review department
• 10 years of experience within hospital utilization management and experience with the formal appeals process
• 10 years progressive experience in a management role with multiple direct reports
• Progressive Management experience, including recent experience of >5+ years in a Director role required