RN Case Mgr

About the Job

General Summary of Position 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 recommendations to alternate tier of Case Management programs or level of care as acuity necessitates.
• 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.
• Provides face-to-face case management in the community as the member/enrollees health necessitates.
• 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, workers 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 departments 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.
• Bachelors degree preferred.

Experience

• 1-2 years Case management experience required.
• 1-2 years UM or related experience required.
• 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.
• 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.

Salary

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