General Summary of PositionResponsible 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.*This role requires you to be on-site in Washington, DC, four days per week, with one remote workday each week.*Key ResponsibilitiesContributes 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 PBMs 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.What We OfferCulture- Collaborative, inclusive, diverse, and supportive work environment.Career growth- Career mentoring to help you pursue your passions and gain skills to enhance your value.Wellbeing- Competitive salary and Total Rewards benefits to help keep you happy and healthy.Reputation- Regional & National recognition, advanced technology, and leading medical innovations.QualificationsADN, BSN, MSN, or CNL from an accredited School of Nursing required.1-2 yearsRecent utilization experience required, 1-2 yearsDiverse clinical experience requiredActive DC RN License required.
This position has a hiring range of $87,318 - $157,289