Works collaboratively with the manager to assist with implementation, integration and operational direction of the Case Management Department within the MedStar Family Choice (MFC). Facilitates the continuum of care, works collaboratively with the interdisciplinary staff, both internal and external to the organization.
We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.
Education- Associate's degree in Nursing required and
- BSN preferred
Experience- 5-7 years Diverse clinical experience required and
- 3-4 years For utilization management (UM), 3 years UM concurrent review experience; for case management (cm), 3 years CM experience required and
- Leadership experience preferred
Licenses and Certifications- Valid RN license in Maryland, Virginia, District of Columbia required or
- any combination as required based on work location(s). required and
- Certified Case Manager (CCM) certification preferred
Knowledge, Skills, and Abilities- Ability to use computer to enter and retrieve data.
- Working knowledge of Microsoft Word, Excel, and PowerPoint applications.
- Effective verbal and written communication skills.
- Must be able to run and analyze departmental productivity reports.
- Excellent interpersonal skills required.
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 leadership, instruction, supervision, and direction to associates in the Case Management Department. Assists with the selection, training, orientation, and assignments of the department staff. Assists with the development of performance standards, and evaluation of associate performance. Initiates and provides recommendations for personnel actions. Maintains ongoing communication with associates to review progress, provide feedback, discuss new developments, and exchange information. Assists in assessing staff professional development and training needs. Identifies training needs related to the clinical software system (data entry / documentation) and programs or processes within the Case Management Department. Implements a plan for training based on identified needs.Provides support to manager's responsibilities and deliverables, including but not limited to the Case Management Department Plan and Appraisal, NCQA submission, EQRO submission, QI UM and other committee reports, program analyses, etc. Provides coverage for the manager as required.Actively develops and manages case management programs and develops individualized plans of care according to NCQA guidelines, COMAR, EQRO, and other regulatory obligations. (Case Management (CM) area).Performs telephonic case management services which includes: assessment, planning, coordinating, implementation, and evaluation. Monitors for timely provision of services. Assists hospital discharge planners and other referral sources with discharge planning. (Case Management (CM) area).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 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.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.Demonstrates emphasis on quality patient care during the pre admission and/or concurrent review process. Authorizes services according to MedStar Family Choice policy.Initiates contact with providers to obtain clinical information to facilitate approval or pending of pre-certification requests, inpatient stays and retrospective reviews. (Utilization Management (UM) area).Processes pre-authorizations for medical necessity, LOC, covered benefits, and participation of the provider. (Utilization Management (UM) area).Performs telephonic inpatient utilization review services which includes: assessment, planning, coordinating, and implementation. Monitors for timely provision of services. Assists hospital case management staff with discharge planning. (Utilization Management (UM) area).Serves as the initial point of contact to support departmental workflows, processes, procedures, SOPs (Standard Operating Procedures), operations, productivity standards, and regulatory requirements (i.e. COMAR, NCQA, EQRO). Maintains current knowledge of benefits, claims, and enrollment issues in order to accurately coordinate member/provider services.Sends thorough reviews to Physician Advisor as appropriate. Coordinates review decisions and notifications, per policy, COMAR guidelines for timely decisions and responses and NCQA guidelines. (Utilization Management (UM) area).Responsible for day-to- day operations of the department, which includes preparation of daily coverage assignments and adjustments as needed. Receives, reviews, processes time off requests and updates staffing calendar. Acts as liaison between IS and the clinical team to identify workflow/system issues and resolutions.Runs productivity reports, collaborates with the manager to analyze reports, and schedules regular meetings with associates to review reports and progress toward goals.Prepares department meeting agendas and co-leads meetings. Assists in preparation and/or review of meeting minutes. Participates in meetings, serves on committees and represents the department in community outreach efforts as appropriate. Participates in multidisciplinary quality and service improvement teams as appropriate.Assists staff in identifying ways to improve the efficiency of the department. Motivates staff to assist with innovations and member and provider engagement. Provides regular feedback on the progress made toward reaching departmental goals.Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.Performs other duties as assigned.
