Remote Utilization Mgmt RN – District of Columbia
- Clinical License RN
- State(s) DC
General Summary of Position
Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services, procedures and facilities. Responsible for clinical review of acute care services based on Medically Necessity criteria, the management of quality health care resources for achievement of desired outcomes, and coordination of alternative levels of care in a timely and in the most cost-effective manner. We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.
Primary Duties and 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.
- Acts as a liaison to MedStar Family Choice (MFC) 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.
- Attends and participates in MFC staff meetings, Clinical Operations department meetings, Special Needs Forums, work groups, etc. as assigned. Provides input, completes assignments, and shares new findings with other staff. Participates in meetings and on committees and represents the department and MFC in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.
- Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.
- Demonstrates skill and flexibility in providing coverage for other staff.
- Identifies inpatients requiring additional services and initiates care with appropriate providers. 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-authorization requests, inpatient stays and retrospective reviews.
- 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 and abuse.
- Performs pre-authorization and pharmacy reviews and documents in PBMÃ†s system when assigned.
- Performs telephonic ACD line coverage for Clinical Operations’ needs.
- Performs telephonic inpatient utilization review services; on-site review as indicated. Process includes: assessment, planning, coordinating, and implementation. Monitors for timely provision of services. Assists hospital case management staff with discharge planning, as applicable.
- Makes referrals to Case Management as needed.
- Sends thorough reviews to Medical Director as appropriate. Coordinates timely review decisions and notifications, per policy, NCQA standards/guidelines and District of Columbia Contract.
- Utilizes evidence-based standards in making coverage determinations in individual patient cases; 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.
- Performs other duties as assigned.
- Valid RN license in the District of Columbia; required and
- Bachelor’s degree preferred
- Recent utilization experience required
- Diverse acute inpatient care clinical experience required
Licenses and Certifications
- RN – Registered Nurse – State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia; required and
- CCM – Certified Case Manager CCM (Certified Case Manager) preferred
Knowledge, Skills, and Abilities
- Proficient computer skills to enter and retrieve data.
- Ability to create, edit and analyze Microsoft office (Word, Excel, and PowerPoint) preferred.
- Knowledge of InterQual guidelines 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 Health
MedStar 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.