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

Minimum Qualifications
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

Primary Duties and Responsibilities

• 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.

Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

• Strong emphasis on teamwork—our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
• Comprehensive total rewards package—including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
• More career opportunities closer to home—as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.