- 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.
-
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 ...
Brentwood $90,000 - $140,000 (USD) per year Full time2 days ago
-
We are seeking a dedicated and skilled Utility Manager to work on challenging and rewarding projects. · This is a full-time position that will support as key personnel or lead large infrastructure projects in the District of Columbia. · The role combines technical review, practic ...
Washington1 week 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
-
· Join our Team as a Utility Manager · Are you ready to play a critical role in large, exciting projects critical to improving infrastructure in our nation's capital? FOXXSTEM is working on 2 of the most high-profile projects in the region We are seeking a dedicated and skilled ...
Washington, DC region, DC1 week ago
-
We are seeking a dedicated and skilled Utility Manager to work on challenging and rewarding projects. · This role combines technical review, practical field perspective, coordination, and process tracking across design and construction phases of large infrastructure projects. · R ...
Washington, DC region1 week 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 ...
Hyattsville $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 ...
Bladensburg $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 ...
College 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 ...
Takoma 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 ...
Capitol Heights $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 ...
Silver Spring $90,000 - $140,000 (USD) per year Full time2 days ago
-
We are seeking a Utilization Management Specialist to support Maryland Medicaid and Medicare programs. · ...
Washington1 month ago
-
Lensa is seeking talented individuals to join their team as Utilization Management Reviewers. In this role, they will evaluate medical necessity for inpatient and outpatient services. · Conduct utilization management reviews by assessing medical necessity, appropriateness of care ...
Washington1 month ago
-
This position will manage activities and staff of the Utilization Review department. · Supervise and evaluate the daily work of these teams in accordance with departmental and organizational policies. Provide education within the departments and the organization at large on clini ...
Washington $97,843 - $163,072 (USD)3 days ago
-
CARIAN is seeking an experienced Utility Project Manager with strong electric distribution experience to support major utility capital programs in the Mid-Atlantic region. · ...
Washington $120,000 - $155,000 (USD)1 week ago
-
We are seeking a detail-oriented healthcare professional to support our Utilization Management Team by coordinating authorizations, · managing denials and appeals, · serving as a liaison between clinical UR staff,This role is essential in ensuring accurate data tracking, · t time ...
Washington $23.65 - $42.03 (USD)1 week ago
-
This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Utility Market Manager - REMOTE. · In this pivotal role, you will influence the future of a reliable and sustainable energy grid. · Develop and execute go-to-market strategies, dri ...
Washington3 weeks ago
-
About The 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 managem ...
Washington $89,065 - $162,801 (USD)3 days ago
-
Nuestro Utilization Management Reviewer evalúa la necesidad médica para servicios hospitalarios e internados. · Conducir revisiones de utilización evaluando la necesidad médica. · ...
Washington $84,400 - $113,600 (USD)1 month ago
-
The Utility Services Maintenance Manager is responsible for overseeing and facilitating the maintenance and repair of water distribution and sewer collection activities through the application of business principles and industry best practices. · Forms crews, assigns work, and in ...
Hyattsville, MD1 month ago
RN Utilization Management - Mount Rainier - 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
-
RN Utilization Management
Full time MedStar Health- Brentwood
-
Utility Manager
Only for registered members Washington
-
Utility Manager
Full time Only for registered members Washington
-
Utility Manager
Only for registered members Washington, DC region, DC
-
Utility Manager
Only for registered members Washington, DC region
-
RN Utilization Management
Full time MedStar Health- Hyattsville
-
RN Utilization Management
Full time MedStar Health- Bladensburg
-
RN Utilization Management
Full time MedStar Health- College Park
-
RN Utilization Management
Full time MedStar Health- Takoma Park
-
RN Utilization Management
Full time MedStar Health- Capitol Heights
-
RN Utilization Management
Full time MedStar Health- Silver Spring
-
Utilization Management Specialist
Only for registered members Washington
-
Utilization Management Reviewer
Only for registered members Washington
-
Manager Utilization Review
Only for registered members Washington
-
Utility Project Manager
Only for registered members Washington
-
Utilization Management Specialist
Only for registered members Washington
-
Utility Market Manager
Only for registered members Washington
-
RN Utilization Management
Only for registered members Washington
-
Utilization Management Reviewer
Only for registered members Washington
-
Utility Services Maintenance Manager
Only for registered members Hyattsville, MD