Nurse Manager, Medical Policy
Requisition #: 184259
Location: Johns Hopkins Health Care,
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: July 19, 2019
Johns Hopkins Health System employs more than 20,000 people annually. When joining the Johns Hopkins Health System, you became part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. Great careers continually advance here.
This position is responsible for the coordination and development of activities and functions of quality improvement initiatives to include planning, design, establishing, and implementation. Provides direction and oversees management of area of responsibility as well as develops and implements policies and procedures and provides recommendation for changes when applicable. Works collaboratively with other teams/departments regarding delegation oversight which includes first tier, downstream, and related entities (FDR) as defined by the Centers for Medicare and Medicaid (CMS) as well as NCQA requirements.
The manager will oversee the daily management of the Medical Policy staff. He/she will ensure that all Medical Policy related deadlines are met. The manager will be responsible for all NCQA, Delmarva and other regulatory requirements related to Medical Policy. The manager will serve as the primary interface with other departments on issues related to Medical Policy development and implementation. He/she will co-manage the medical policy budget.
Requires a Bachelor’s degree in Nursing or related health care administration field. Master’s degree in Nursing or Healthcare Administration preferred. RN with equivalent work experience may be substituted as appropriate.
Requires professional level of knowledge NCQA ®, HEDIS ® and VBP measures, Quality Care Standards, accreditation, audit and review processes.
Knowledge of Microsoft Office and Access/Excel databases.
Work requires knowledge of health care, managed care, coding, medical coverage policy and evidence based medicine. Knowledge of medical policy tools including InterQual®, Hayes, Tricare policies and COMAR a must.
Strong supervisory skills; must plan and direct the work of a diversified staff.
Strong analytical ability to solve complex problems. Must possess advanced interpersonal skills to effectively interface with all levels of staff as well as external business-related associates.
Requires leadership ability to effectively communicate (oral and written) and direct area staff.
Requires excellent analytical, organizational, oral and written communications skills, the ability to manage multiple tasks and priorities, the ability to independently resolve complex issues and keep management appropriately informed. Also requires good leadership and team building skills. Work requires reinforcing accountability for meeting deadlines and quality standards, identifying opportunities for process and procedural improvements, ability to handle sensitive and confidential information, and the ability to communicate and exchange information with all internal and external customers.
Must possess proficient PC skills and demonstrate proficient usage of various types of software to include spreadsheets, databases, etc. In addition, has the ability to use highly specialized/customized software for database management and preparation.
D. Required Licensure, Certification, Etc.:
Requires active licensure as a Registered Nurse in the State of Maryland. Health Care Quality or Safety Certification preferred.
E. Work Experience:
Requires at least five years of experience with specified subject matter. Must have experience with conducting and monitoring the medical record review process. Three Years Management or Supervisory experience required.
F. Machines, Tools, Equipment:
General office and communications equipment.
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.