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Company: MedStar Medical Group
Location: Washington, DC
Career Level: Mid-Senior Level
Industries: Not specified

Description

General Summary of Position
Provides support for the Care Management Department by coordinating and promoting comprehensive quality cost-effective care.


Primary Duties and Responsibilities

  • Assists in the identification of potential Case Management candidates through clinical review, selected diagnoses, etc. and makes appropriate referrals.
  • 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.
  • Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.
  • Identifies and reports potential coordination of benefits, subrogation, third party liability, workers compensation cases, etc. Identifies quality, risk, or utilization issues to appropriate MedStar personnel.
  • Initiates contact with providers to obtain clinical information to facilitate care or pending pre-certification requests. Interacts with assigned disease management populations of limited volume. Interaction is designed to improve patient access to care, and education regarding the disease and support services.
  • Maintains current knowledge of MedStar Family Choice benefits and enrollment issues in order to accurately coordinate services.
  • Maintains expertise in general benefit management and serves as a resource for MedStar Family Choice members, physicians, and staff for benefit interpretation and coordination.
  • Maintains timely and accurate documentation in the IS System per Case Management policy.
  • Participates in meetings, work groups, etc. as assigned.
  • Processes pre-authorizations for medical necessity, LOC, covered benefits, and participation of the provider at the discretion of the guidelines and Medical Reviewer.
  • Sends reviews to Medical Reviewer as appropriate. Coordinates review decisions and notifications, per policy.
  • Provides after-hour coverage as required to meet departmental standards and District of Columbia contract.

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    Minimum Qualifications
    Education

    • Valid LPN License in the State of Maryland. required

    Experience

    • 1-2 years Utilization review experience required and
    • 3-4 years Diverse clinical experience required

    Licenses and Certifications

    • LPN - Licensed Practical Nurse - State Licensure Valid LPN license in the State of Maryland or District of Columbia. Upon Hire required

    Knowledge, Skills, and Abilities

    • Knowledge of current trends in healthcare delivery and utilization review criteria.
    • Ability to use computer to enter and retrieve data.
    • Ability to create, edit and analyze (Word, Excel and PowerPoint) preferred


    This position has a hiring range of $60,632 - $107,494

     


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