RN In Hospital Transiton of Care Case Manager

About the Job

General Summary of Position

An exciting new role has been added to the team, offering a unique opportunity to make a direct impact on patient outcomes at a critical point in care. The In-Hospital Transition of Care RN Case Manager partners closely with hospital discharge planners to coordinate patient care at discharge, ensuring seamless continuity across care settings and reducing avoidable readmissions through proactive coordination, patient education, and timely follow-up.

This position is based at either Washington Hospital Center or The Psychiatric Institute of Washington (PIW) and offers the opportunity to work across diverse patient populations, with flexibility to provide coverage at both locations. In this highly collaborative and autonomous role, the RN Case Manager manages a complex caseload and takes ownership of case management program(s), driving high-quality, cost-effective outcomes while enhancing the patient experience.

The role includes coordinating and managing care for members/enrollees, completing pre-authorization reviews to ensure medical necessity and timely access to services, and conducting pharmacy reviews aligned with the population served. Working alongside an interdisciplinary team, you will play a key role in discharge planning, connecting patients to the right resources, and ensuring smooth transitions across the continuum of care.

This is an excellent opportunity for a nurse who thrives in a fast-paced environment, values critical thinking and autonomy, and is passionate about improving care transitions and patient outcomes. We are committed to fostering a supportive, inclusive environment where associates from diverse backgrounds can grow, advance, and make a meaningful difference.

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 tiers 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 programs utilize 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 Operations 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.

Compensation

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