General Summary of Position
This position reports to the office 4 days a week with aschedule of 8:30A - 5:00P. A hybrid / flex schedule is possible in the future.
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.
Minimum Qualifications
Education
- Graduate of an accredited School of Nursing required and
- Bachelor's degree preferred
Experience
- 3-4 years Case management experience required and
- 3-4 years UM or related experience required and
- 5-7 years diverse clinical experience required and
- 3-4 years acute inpatient care 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 $87,318 - $157,289