Clinical Utilization Manager

1 month ago


Washington, United States MedStar Health Full time
Job Summary

Clinical Utilization Managers play a vital role in ensuring that patients receive the most appropriate level of care while minimizing unnecessary costs. At MedStar Health, we seek a seasoned RN with expertise in utilization review and case management to join our team as a Clinical Utilization Manager.

About the Role

In this critical position, you will conduct thorough admission, concurrent, and retrospective case reviews to guarantee that patients receive the correct level of care according to nationally approved guidelines. Your collaboration with medical staff and other hospital disciplines will be crucial in delivering high-quality patient care efficiently.

Main Responsibilities

• Conduct admission, concurrent, and retrospective case reviews to ensure alignment with hospital objectives of efficient and quality patient care
• Foster a culture of high-quality patient care by adhering to organizational policies, procedures, and quality standards, and complying with governmental and accrediting agency regulations
• Collaborate closely with medical staff, physician advisors, social workers, and other ancillary hospital disciplines to meet patients' health care needs cost-effectively
• Perform medical record reviews, document relevant information, and communicate with third-party payors in a timely manner to ensure proper hospital reimbursement and minimize unnecessary denials
• Develop strategies to avoid potential denials by communicating effectively with key stakeholders, including attending physicians
• If necessary, implement non-coverage, ABN, MOON letters, and other relevant documents in accordance with organizational, governmental, and accrediting organization policies and regulations
• Participate actively in IDRs, Length of Stay, and other meetings as per hospital policies
• Identify potential risks related to patient care and communicate them with the appropriate hospital disciplines, including risk management, quality, safety, and infection control
• Serve as a resource to the healthcare team by educating them through in-services, staff meetings, and formal educational settings on areas of utilization management
• Demonstrate current knowledge of state and federal regulatory requirements regarding the utilization review process
• Recognize dynamics of neglect/abuse and report them to the relevant in-house departments and governmental agencies as needed

Requirements

We are seeking a dedicated and experienced professional with:
  • A minimum of 3-4 years of experience in an acute care setting, required
  • 2 years of experience in case management, insurance, utilization review, or a related field preferred

  • RN - Registered Nurse State Licensure and/or Compact State Licensure in the District of Columbia or the State of Maryland depending on work location, required
  • CCM - Certified Case Manager, preferred

  • Excellent problem-solving skills and ability to exercise independent judgment
  • Business acumen and leadership skills
  • Strong verbal and written communication skills with the ability to effectively interact with all levels of management, internal departments, and external agencies
  • Working knowledge of various computer software applications

Hiring Salary Range: $87,318 - $157,289

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