RN Case Mgr

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Coordinates, negotiates, procures and manages the care of our members/enrollees to facilitate cost‑effective care and member/enrollee satisfaction. Facilitates the continuum of care and works collaboratively with interdisciplinary staff both internal and external to the organization. Responsible for carrying a complex case‑management case load, owning a case‑management program(s), conducting pre‑authorization reviews, providing medically necessary timely and quality health care services, and performing pharmacy reviews for the population served.

Recruits, retains and advances associates with diverse backgrounds, skills and talents equitably at all levels.

• 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 Med Star 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 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/enrollee’s health necessitates.
• Demonstrates behavior consistent with Med Star 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, assessments 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 Med Star 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 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 multidisciplinary quality and service improvement teams.

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

• 1-2 years case management experience required.
• 1-2 years utilization management or related experience required.
• 3-4 years diverse clinical experience required.

• 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.

• Verbal and written communication skills.
• Ability to use computer to enter and retrieve data.
• Ability to create, edit and analyze documents in Microsoft Office (Word, Excel and PowerPoint). Preferred.

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

Mid-Senior Level

Full-time

Health Care Provider

Hospitals and Health Care