General Summary of PositionPosition SummaryReview and facilitation of the Continuum of Care to achieve desired clinical outcomes.Outcomes attained collaboratively with participation of patients, family members, physicians, health care providers and others.Key ResponsibilitiesPerforms integrated patient care quality monitoring: Utilizes Medical Staff approved comprehensive monitors that measure/evaluate: o Operative and Invasive procedures o Peri-natal o Infection Control o Stability at Discharge o Utilization o Case Review Immediately notifies the Quality and Accreditation Improvement Department of urgent/critical quality issues.Identifies cases for potential peer review and reports these cases to the Quality and Accreditation Department. Documents all screening and outcome variations according to Quality & Accreditation Department process. Assists MSMHC achieve compliance in the important functions described in the Joint Commission manual.Performs utilization review, regardless of payor source, in accordance with the Utilization Management Plan in accordance with State of Maryland Regulations. Utilizes Medical Staff approved monitors for ongoing measurement/evaluation of utilization management.Maintain current clinical records according to department policy and professional standards and prepares monthly statistical reports. Is available on a rotating basis on weekends, evenings, and holidays with other staff to provide onsite services from utilization review.Performs the “denial” process for all patients according to particular payor. Advises the physician of appropriate commercial insurer requirements, such as Medical Assistance second opinion requirement. Performs clinical review, upon request of Patient Accounts, for appeals, and Medicaid Administrative Days. Completes appeal process for denial days that appear to be clinically justified.Readily distinguishes between acute, intermediate and skilled levels of care. Contacts managed care companies on a daily basis to assure reimbursement for continued stay. Refers concurrent utilization problems/issues to the Physician Advisor for review.Completes, in a timely manner, admission and continues stay criteria review to obtain “certification” and/or continues stay approval for selected Medicare, Medicaid, commercial and managed care patients. Refers individual patient reviews that do not meet status criteria to Executive Health Resources (EHR) as per contractFacilitates the “Continuum of Care” through coordination of the discharge planning process: Upon referral, assess patient discharge planning needs and social factors related to patient care. Consults with the physician(s) to obtain essential information including the post discharge treatment plan and communicates this treatment plan to other health care providers, internal and external, to assure the continuity of the patient’s care.Maintains current clinical records according to department policy and professional standards and prepares monthly statistical reports. Is available to be on site on a rotating basis on weekends, evenings and holidays with other staff to provide discharge planning, telephone consultation, resource information and referrals for Home Health and medical equipment.Counsels patients and significant other regarding financial assistance and makes appropriate referrals where needed. Assesses level of care for patients in need of long term placement and obtains appropriate placement. Coordinates long term or short term placement with the physician, patient, significant other and internal/external health care providers.Documents assessment, discharge plan, problems, services, and outcomes in the medical record in a clear and concise manner with consideration of the patient’s age, developmental needs, diagnosis and employee area of specialization. Makes referrals and arranges for needed services for home careCoordinates multi disciplinary clinical management conferences. Assists the patient and significant other in assessing discharge options and determining a plan for continuing care within the limits of resources, personal preferences, regulations, and medical needs.Assures the provision of clinical social services to meet the needs of our patients and their significant others. Makes appropriate referrals to Pastoral Care to meet the spiritual needs of our patients and significant other. Makes appropriate referrals to community action groups, support groups, etcetera. Complies with the State law for reporting abuse/neglect for children and adults.Completes a psychosocial history and assessment for patients identified as high risk that is maintained as a permanent part of the medical record. Evaluates social and significant other information and assists in determining treatment plans relevant to patient’s background, age, and emotional/cognitive needs.Identifies high risk patients (through predetermined screening criteria) and makes prompt appropriate referrals to social services/social workers. Works in concert with Social Workers/Social Services to meet the needs of our patients and significant other.Communicates with others in an effective, professional manner: Maintains confidentiality in accordance with hospital policy. Maintains open communication with MSMHC staff.Communicates effectively, courteously and compassionately with all patients, families, visitors, physicians. Utilizes appropriate channels of communication to address interdepartmental concerns and opportunities for improvement. Serves as patient advocate in assuring a collaborative approach to patient care management.Medical Staff, patients, significant others, nursing and health care providers as appropriate, (internal and external) to facilitate the case management process and enable patients to make informed decisions regarding their plan of treatment and discharge disposition.Participates in organizational improvement: Participates in improving processes related to the Continuum of Care, Performance Improvement, and The Joint Commission Important Functions as appropriate. Participates in the formulation and revision of policies and procedures related to the case management process.Demonstrates a commitment to professionalism and self-improvement: Attends required departmental staff meetings. Participates in the Joint Commission related educational programs.Participates in related educational programs that promote clinical and case management expertise. Participates or provides at least one educational program annually for SMHC staff. Accepts other related duties as assigned by the Director.What We OfferCulture- Collaborative, inclusive, diverse, and supportive work environment.Career growth- Career mentoring to help you pursue your passions and gain skills to enhance your value.Wellbeing- Competitive salary and Total Rewards benefits to help keep you happy and healthy.Reputation- Regional & National recognition, advanced technology, and leading medical innovations.QualificationsADN, BSN, MSN, or CNL from an accredited School of Nursing required.1-2 years of experience required, 3-4 years of experience preferred.Active MD RN License or Active Compact State RN and Basic Life Support for Healthcare providers required.CCM Certification preferred
Why MedStar Health At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:
Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.
About MedStar HealthMedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.