Job Description

Provides support for the Care Management Department by coordinating and promoting comprehensive quality cost-effective care.
Education

• Valid LPN License in the State of Maryland. required and

Experience

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

Licenses and Certifications

• Valid LPN license in the State of Maryland. 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
• Acts as a liaison to MedStar Managed Care contracted vendors to facilitate care.
• 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 of pre-certification requests and pharmacy management issues. Recommends use of appropriate in network/ formulary benefits.
• 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 pharmacy benefit management and/or general benefit management and serves as a resource for MedStar Family Choice members, physicians, and staff for benefit interpretation, alternatives, and coordination.
• Maintains timely and accurate documentation in the IS System per Case Management policy.
• Participates in staff meetings, Care Management meetings, Pharmacy and Therapeutics Committee, work groups, etc. as assigned. Provides input, completes assignments and shares new findings with staff.
• Processes pre-authorizations for medical necessity, LOC, covered benefits, and participation of the provider.
• Sends thorough reviews to Physician Advisor as appropriate. Coordinates review decisions and notifications, per policy.
• 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.
• Provides after-hour coverage as required to meet departmental standards and District of Columbia contract.

MedStar Health