(RN) Case Manager - Relocation Offered!

General Summary of Position

(RN) Case Manager

Medstar wants you to join our amazing Clinical Operations Team!

Our nurse would be a change agent by utilizing their case management skills to effectively evaluate moderate to highly complex cases. As a member of the Case Management Team, you would liaise between providers and insurance entities to facilitate the delivery of quality, cost effective, patient-centered care. Ensuring that the care is designed to meet individualized patient outcomes. The ideal candidate would :

• Possess a strong clinical background in chronic conditions
• Understand the authorization process
• Have successful outcomes with complex case management and care coordination
• Understand and adhere to strict guidelines, timeliness, and documentation processes
• Feel comfortable speaking to providers and patients regarding sensitive topics
• Medicaid case management is a plus
• Strong telephonic skills

This is a hybrid position with general operating hours of Monday-Friday, 8 : 30 am to 5 pm with 2 Days in Office 3 days Remote.

This position is currently working out of the King Ave, Baltimore office, but will transition to the Columbia office in December 2025.

If interested, please apply today!

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.

Actively develops and manages complex case management cases and develops individualized plans of care according to NCQA standards / guidelines and the District of Columbia Contract.

Acts as a liaison to MedStar Family Choice contracted vendors to facilitate care. Identifies gaps in contracted services and develops a plan to access care.

Acts as an advocate while assisting members / enrollees 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.

Assists hospital case management staff with discharge planning, if applicable. Makes recommendation to alternate tier of Case Management programs or level of care as acuity necessitate.

Attends and participates in MFC staff meetings, Clinical Operations department meetings, Special Needs Forums, work groups, District / community agencies meetings, etc. as assigned. Provides input, completes assignments, and shares new findings with other staff. 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.

Provides face to face case management in the community, as the member / enrollee's health necessitate.

Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.

Demonstrates skill and flexibility in providing coverage for other staff.

For assigned Case Management program(s), develops strategies, assessment(s), and evaluation / goal tools according to NCQA standards / guidelines and District of Columbia Contract for the population served. Utilizes standards / guidelines to manage and document interactions for the program (s). Responsible for verifying that assigned program utilizes up-to-date standards in the medical and behavioral health community for the population served. Keeps informed about disease processes, treatment modalities, and resources.

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.

Identifies inpatients requiring additional services and initiates care with appropriate practitioners.

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 Operation department's policy.

Monitors utilization of all services for fraud, waste and abuse.

Performs telephonic ACD line coverage for Clinical Operations' needs.

Enters authorization as appropriate to the program and sends the reviews to Medical Director as appropriate. Coordinates review decisions and notifications, per policy, NCQA standards / guidelines and District of Columbia Contract for timely decision making.

Participates in meetings and on committees and represents the department and hospital in community outreach efforts.

Participates in multi-disciplinary quality and service improvement teams.

Minimum Qualifications

Education

Experience

Licenses and Certifications

Knowledge, Skills, and Abilities

This position has a hiring range of $89,065 - $162,801