MedStar Health

General Summary of Position

Unit Highlights

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.

• This position is 4 days on-site in our office in DC, with 1 remote day per week*

We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.

Key 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 recommendation to alternate tier
• of Case Management programs or level of care as acuity necessitate.
• 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. 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.
• 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 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.

What We Offer

• Culture- 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.

Qualifications

• ADN, BSN, MSN, or CNL from an accredited School of Nursing required.
• 1-2 years of Case Management experience required, and 1-2 years of UM or related experience required, and 3-4 years diverse clinical experience required.
• Active DC RN License required.

This position has a hiring range of $87,318 - $157,289