RN Case Management
Rn- Case Management Utilization Review MedStar Southern Maryland Hospital Center, located in Clinton, Maryland, is an award winning, acute care hospital focused on caring for patients and their loved ones utilizing advanced technology under the guidance of expert clinicians. Quality, Safety, Wellness, and Patient Satisfaction are achieved through a spirit of patient centered services that connect us to the community we serve. If you believe in patient focused care, excellence, teamwork, and are committed to meeting the needs of our patients and customers, we invite you to join our team! MedStar Southern Maryland Hospital Center is actively recruiting for a fulltime RN, Case Management, to join our dedicated team! Primary Duties and Responsibilities: Performs integrated patient care quality monitoring: Utilizes Medical Staff approved comprehensive monitors that measure/evaluate: Operative and invasive procedures Per-natal Infection Control Stability at Discharge Utilization Case Review Immediately notifies the Quality and Accreditation Improvement Department of urgent/critical quality issues. Identifies cases for potential peer review and reports these cases to the Quality and Accreditation Department. Medicare patients not meeting Inter Qual. Criteria will be forwarded to Executive Health Resources ( EHR ) for second level physician review as per MSMHC UR plan. Assists MSMHC achieve compliance in the important functions described in the Joint Commission manual. Performs utilization review, regardless of payor source, in accordance with the Utilization Management Plan in accordance with the State of Maryland regulations. Utilizes Medical Staff approved monitors for ongoing measurement/evaluation of utilization management. Completes, in a timely manner, admission and continues stay criteria review to obtain certification and/or continues stay approval for selected Medicare, Medicaid, commercial and managed care patients. Refers individual patient reviews that do not meet status criteria to Executive Health Resources ( EHR ) as per contract. Readily distinguishes between observation acute, intermediate and skilled levels of care. Contacts managed care companies on a daily basis to assure reimbursement for continued stay. Refers concurrent utilization problems/issues to the Physician Advisor for review. Performs the denial process for all patients according to particular payor. Advises the physician of appropriate Medicare, commercial insurer requirements, and medical Assistance second opinion requirements. Performs clinical review, upon request of Patient Accounts, for appeals, and Medicaid Administrative Days. Completes appeal process for denial days that appear to be clinically justified. Maintains current clinical records according to department policy and professional standards and prepares monthly statistical reports. Is available to be on a rotating basis on weekends, evenings and holidays with other staff to provide onsite Utilization review services. Communicates with others in an effective, professional manner: Maintains confidentiality in accordance with hospital policy. Maintains open communication with MSMHC staff, Medical Staff, patients, significant others, nursing and health care providers as appropriate, (internal & external) to facilitate the process and enable patients to make informed decisions regarding their plan of treatment and discharge disposition. Communicates effectively, courteously and compassionately with all patients, families, visitors, and physicians. Utilizes appropriate channels of communication to address interdepartmental concerns and opportunities for improvement. Serves as patient advocate in assuring a collaborative approach to patient care management. Participates in organizational improvement: Participates in improving processes related to the Continuum of Care, Performance Improvement, and the Joint Commission Important Functions as appropriate. Participates in the formulation and revision of policies and procedures related to the case management process. Demonstrates a commitment to professionalism and self-improvement Attends required departmental staff meetings. Participates in related education programs. Participates in the Joint Commission related educational programs. Participates in related educational programs that promote clinical and case management expertise. Participates or provides at least one educational program annually for MSMHC staff. Accepts other related duties as assigned by the Director. Qualifications: BSN or BS preferred 3-5 years minimum experience working in case management Current Maryland State Nursing License Certified Case Manager Certified Professional in Utilization Management CPR About MedStar HealthMedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, DC, region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association 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 is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.