MedStar Health
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 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 multidisciplinary 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 PBM’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.
Minimal Qualifications Education
Valid RN license in the District of Columbia or Maryland (required).
Bachelor's degree preferred.
Experience
1-2 years recent utilization experience required.
1-2 years diverse clinical experience required.
Licenses and Certifications
RN – Registered Nurse – State Licensure and/or Compact State Licensure (valid RN license in the District of Columbia or Maryland upon hire required).
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.
Salary Range USD $87,318.00 – USD $157,289.00 per year.
Seniority Level Not Applicable.
Employment Type Full‑time.
Job Function Health Care Provider.
Industries Hospitals and Health Care.
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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 multidisciplinary 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 PBM’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.
Minimal Qualifications Education
Valid RN license in the District of Columbia or Maryland (required).
Bachelor's degree preferred.
Experience
1-2 years recent utilization experience required.
1-2 years diverse clinical experience required.
Licenses and Certifications
RN – Registered Nurse – State Licensure and/or Compact State Licensure (valid RN license in the District of Columbia or Maryland upon hire required).
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.
Salary Range USD $87,318.00 – USD $157,289.00 per year.
Seniority Level Not Applicable.
Employment Type Full‑time.
Job Function Health Care Provider.
Industries Hospitals and Health Care.
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr