RN Case Manager Utilization Review

MedStar Health; Columbia (MD); On-site; USD 89,000 - 163,000; Full time

Job summary

MedStar Health is seeking a Registered Nurse to manage complex case loads and coordinate care for members enrolled with MedStar Family Choice. This role emphasizes NCQA standards, quality care, and cost-effective service delivery across medical, psychiatric, psychosocial and other essential needs.

Responsibilities include developing individualized care plans, advocating for access to services, coordinating with hospitals and external partners, documenting thoroughly, and participating in

Qualifications

• RN license required; District of Columbia and/or Maryland licensure based on work location.
• CCM certification is preferred.
• 1-2 years case management and 1-2 years UM or related experience; 3-4 years diverse clinical experience.

Responsibilities

• Coordinate and manage a complex case management caseload in accordance with NCQA standards and DC contract.
• Act as liaison to MedStar Family Choice contracted vendors to facilitate access to care.
• Advocate for members/enrollees to coordinate and obtain medical, psychiatric, psychosocial, and other services.
• Assist with discharge planning and provide recommendations on care levels as acuity necessitates.
• Document timely and accurate information in the clinical software system and monitor utilization for quality and safety.

Skills

Verbal communication

Written communication

Computer skills

MS Office

Education

RN Licensure

Bachelor's degree preferred

Job description

About the Job

Coordinates negotiates procures and manages care of our members/enrollees to facilitate cost effective care and members/enrollees satisfaction. Facilitates the continuum of care works collaboratively with interdisciplinary staff internal and external to the organization. Responsible for carrying a complex case management case load ownership of a case management program(s) pre- authorization reviews to provide Medically Necessary timely and quality health care services in the most cost-effective manner and pharmacy reviews per population served.We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Actively develops and manages complex case management cases and develops individualized plans of care according to NCQA standards/ guidelines and the District of Columbia Contract.
• Acts as a liaison to MedStar Family Choice contracted vendors to facilitate care. Identifies gaps in contracted services and develops a plan to access care.
• Acts as an advocate while assisting members/enrollees to coordinate and gain access to medical psychiatric psychosocial and other essential services to meet their healthcare needs. Authorizes and monitors covered services according to policy.
• Assists hospital case management staff with discharge planning if applicable. Makes recommendation to alternate tier of Case Management programs or level of care as acuity necessitate.
• Attends and participates in MFC staff meetings Clinical Operations department meetings Special Needs Forums work groups District/ community agencies meetings etc. as assigned. Provides input completes assignments and shares new findings with other staff. Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Provides face to face case management in the community as the member/enrollee's health necessitate.
• Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
• Demonstrates skill and flexibility in providing coverage for other staff.
• For assigned Case Management program(s) develops strategies assessment(s) and evaluation/goal tools according to NCQA standards/ guidelines and District of Columbia Contract for the population served. Utilizes standards/ guidelines to manage and document interactions for the program (s). Responsible for verifying that assigned program utilizes up-to-date standards in the medical and behavioral health community for the population served. Keeps informed about disease processes treatment modalities and resources.
• Identifies and reports potential coordination of benefits subrogation third party liability worker's compensation cases etc. Identifies quality risk or utilization issues to appropriate MedStar personnel.
• Identifies inpatients requiring additional services and initiates care with appropriate practitioners.
• Maintains current knowledge of MFC benefits and enrollment issues in order to accurately coordinate services.
• Maintains timely and accurate documentation in the clinical software system per Clinical Operation department's policy.
• Monitors utilization of all services for fraud waste and abuse.
• Performs telephonic ACD line coverage for Clinical Operations' needs.
• Enters authorization as appropriate to the program and sends the reviews to Medical Director as appropriate. Coordinates review decisions and notifications per policy NCQA standards/ guidelines and District of Columbia Contract for timely decision making.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
• Participates in multi-disciplinary quality and service improvement teams.

Minimal Qualifications

Education

• Graduate of an accredited School of Nursing required and
• Bachelor's degree preferred

Experience

• 1-2 years Case management experience required and
• 1-2 years UM or related experience required and
• 3-4 years Diverse clinical experience required

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia and/or the State of Maryland based on work location(s) Upon Hire required and
• CCM - Certified Case Manager Upon Hire preferred

Knowledge Skills and Abilities

• Verbal and written communication skills. Ability to use computer to enter and retrieve data. Ability to create edit and analyze Microsoft office (Word Excel and PowerPoint) preferred.

This position has a hiring range of USD $89,065.00 - USD $162,801.00 /Yr.