General Summary of PositionPosition SummaryCoordinates, 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.*4 days per week on-site in DC*Key ResponsibilitiesContributes 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 accordingto 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 servicesand 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 servicesaccording to policy.Assists hospital case management staff with discharge planning, if applicable. Makes recommendation to alternate tierof Case Management programs or level of care as acuity necessitate.Attends and participates in MFC staff meetings, Clinical Operations department meetings, Special Needs Forums, workgroups, District/ community agencies meetings, etc. as assigned. Provides input, completes assignments, and sharesnew findings with other staff. Contributes to the achievement of established department goals and objectives andadheres to department policies, procedures, quality standards, and safety standards. Complies with governmental andaccreditation 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 ColumbiaContract 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.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.3-4 years Case Management experience required, 3-4 years UM or related experience required, 5-7 years diverse clinical experience required, and 3-4 years acute inpatient care clinical experience required.Active DC RN License and Basic Life Support for Healthcare providers required.
This position has a hiring range of $87,318 - $157,289