- 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 PBMÆs 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.
- Valid RN license in the District of Columbia; or Maryland required and
- Bachelor's degree preferred
- 1-2 years Recent utilization experience required and
- 1-2 years Diverse clinical experience required
- RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia; or Maryland Upon Hire required and
- CCM - Certified Case Manager CCM (Certified Case Manager) Upon Hire preferred
- 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.
-
Site Name: USA - Maryland - Rockville · Posted Date: Feb · We manufacture and supply reliable, high-quality medicines and vaccines to meet patients' needs and drive our performance. · Our network of 37 medicines and vaccines manufacturing sites delivered 1.7 billion packs of med ...
Rockville $113,025 - $188,375 (USD)1 day ago
-
We manufacture and supply reliable, high-quality medicines and vaccines to meet patients' needs and drive our performance. · Our network of 37 medicines and vaccines manufacturing sites delivered 1.7 billion packs of medicines and 409 million vaccine doses in 2024 to help make a ...
Rockville $113,025 - $188,375 (USD) Full time1 day ago
-
About this Job: 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 manage ...
Derwood $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Washington Grove $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Garrett Park $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Gaithersburg $90,000 - $140,000 (USD) per year Full time2 days ago
-
Bowman has an opportunity for a Dry Utility Project Manager to join our team in one of the offices in our DC Metro region. · ...
Derwood2 weeks ago
-
About this Job: 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 manage ...
Potomac $90,000 - $140,000 (USD) per year Full time2 days ago
-
Short Description · Bowman has an opportunity for a Dry Utility Project Manager to join our team in one of the offices in our DC Metro region. · At Bowman, we believe in creating opportunities for aspiring people to thrive and achieve ambitious goals. That's why a career at Bowma ...
Derwood, MD4 days ago
-
About this Job: 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 manage ...
Kensington $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Olney $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Montgomery Village $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Chevy Chase $90,000 - $140,000 (USD) per year Full time2 days ago
-
Bowman has an opportunity for a Dry Utility Senior Project Manager to join our team in one of our offices in the DC Metro region. · ...
Derwood1 month ago
-
About this Job: 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 manage ...
Bethesda $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Glen Echo $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Cabin John $90,000 - $140,000 (USD) per year Full time2 days ago
-
About this Job: 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 manage ...
Sandy Spring $90,000 - $140,000 (USD) per year Full time2 days ago
-
Supports the Utilization Management clinical teams by assisting with non-clinical administrative tasks and responsibilities related to pre-service, utilization review, care coordination and quality of care. · ...
Reston1 month ago
-
JoinourTeamas a Utility Manager · Are you ready to play a critical role in large, exciting projects critical to improving infrastructure in our nation's capital? We are seeking a dedicated and skilled Utility Manager to work on challenging and rewarding projects. This is a full- ...
Washington Full time1 week ago
RN Utilization Management - Rockville - MedStar Health
Description
About this Job: 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
Minimal Qualifications
Education
Experience
Licenses and Certifications
Knowledge Skills and Abilities
-
Manager Utilities Maintenance
Only for registered members Rockville
-
Manager Utilities Maintenance
Full time Only for registered members Rockville
-
RN Utilization Management
Full time MedStar Health- Derwood
-
RN Utilization Management
Full time MedStar Health- Washington Grove
-
RN Utilization Management
Full time MedStar Health- Garrett Park
-
RN Utilization Management
Full time MedStar Health- Gaithersburg
-
Dry Utility Project Manager
Only for registered members Derwood
-
RN Utilization Management
Full time MedStar Health- Potomac
-
Dry Utility Project Manager
Only for registered members Derwood, MD
-
RN Utilization Management
Full time MedStar Health- Kensington
-
RN Utilization Management
Full time MedStar Health- Olney
-
RN Utilization Management
Full time MedStar Health- Montgomery Village
-
RN Utilization Management
Full time MedStar Health- Chevy Chase
-
Dry Utility Senior Project Manager
Only for registered members Derwood
-
RN Utilization Management
Full time MedStar Health- Bethesda
-
RN Utilization Management
Full time MedStar Health- Glen Echo
-
RN Utilization Management
Full time MedStar Health- Cabin John
-
RN Utilization Management
Full time MedStar Health- Sandy Spring
-
Utilization Management
Only for registered members Reston
-
Utility Manager
Full time Only for registered members Washington