RN Utilization Management

General Summary of Position

Qualifications, skills, and all relevant experience needed for this role can be found in the full description below.
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 Med Star 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 Med Star 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 Med Star 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 Med Star personnel.

Minimal Qualifications
Education

• Valid RN license in the District of Columbia; or Maryland required and
• Bachelor's degree preferred

Experience

• 1-2 years Recent utilization experience required and
• 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 and
• CCM - Certified Case Manager CCM (Certified Case Manager) Upon Hire 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. xrlwcon
• Knowledge of Inter Qual guidelines preferred.