Nurse Manager Utilization Management (RN) - Relocation Offered!

Company: MEDSTAR HEALTH
Location: Washington
Posted on: May 22, 2025

Job Description:

General Summary of Position
Responsible for evaluating the necessity, appropriateness and efficiency of the use of medical services procedures and facilities.
Responsible for clinical review of all acute services for appropriateness based on medical criteria, the management of healthcare
resources necessary and appropriate for achievement of desired outcomes, and the coordination of alternative levels of care for
enrollees/members. Works collaboratively with interdisciplinary staff, both internal and external to the organization to facilitate the
continuum of care, through education and advocacy to enhance health outcomes.We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.
Key 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 leads the process of validating medical necessity by utilizing pre-approved criteria and guidelines for continued
  stay and appropriateness of treatment and discharge planning.
• Acts as a liaison between IS and the clinical team to identify workflow / system issues and resolutions. Uses technology
  to enhance decision making and effectiveness.
• Analyzes the UM monthly reports on LOS, Days per 1000, readmissions, physician denials, denial rates at acute
  facilities, productivity and other reports as required by MFC Clinical Operations. Reports trends/findings to the Director
  on at least a monthly basis.
• Assists staffs with setting personal and educational goals and objectives to enhance their professional development.
  Develops and implements education programs to coordinate staff development and training needs both for software and clinical training issues.
• Assists with hiring, training, orientation and assignments of department staff. Assists with the development and
  evaluation of performance standards. Initiates or makes recommendations for personnel actions. Maintains regular
  ongoing communication with subordinates to review progress, provide feedback, discuss new developments, and
  exchange information.
• Collaborates with the Director and contributes to the achievement of department goals and objectives and adheres to
  department policies, procedures, quality standards, and safety standards.
• Direct management of the Utilization Management Team to assure and maintain high quality and productivity standards;
  ensure results-oriented utilization management, timely customer service follow-up and strong communication skills.
• Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.
• Demonstrates skill and flexibility in providing coverage for staff and other department managers.
• Educates and monitors staff regarding timely and accurate documentation in the clinical software system per Clinical
  Operations policies.
• Ensures compliance with governmental and accreditation regulations.
• Leads staff meetings, weekly census, work groups, etc., as assigned. Addresses issues impacting MFC with community
  agencies and providers. Delivers updated information back to department staff.
• Maintains current knowledge and functions as a resource to the clinical team regarding benefits, authorizations,
  enrollment issues, practice guidelines and alternative treatment options in order to accurately coordinate
  enrollees/provider services.
• Manages ACD telephone coverage and processes related to PCP and provider questions, eligibility and benefits,
  transportation, and authorization issues.
• Monitors and ensures compliance with UM standards, as per MFC policies and procedures.
• Provides backup support in the absence of the Director as required. Works in partnership with the Manager of Case
  Management and other Managers as appropriate in development of the annual Clinical Operations Plan and the Clinical
  Operations Appraisal.
• Provides continuing individual coaching and support to staff and acts as a resource for clinical, social, utilization and
  appeal review issues as they relate to the Clinical Operations department.
• Serves as a first line intermediary in inter-associate disagreements; knowing when to escalate issues to the next level of management.
• Performs other duties as assigned.What We Offer
  
  • 
    
  • Culture- Collaborative, inclusive, diverse, and supportive work environment.
    
  • Career growth- Career mentoring to help you pursue your passions and gain skills to enhance your value.
    
  • Wellbeing- Competitive salary and Total Rewards benefits to help keep you happy and healthy.
    
  • Reputation- Regional & National recognition, advanced technology, and leading medical innovations.
    
    Qualifications
    
    • BSN from an accredited School of Nursing required.
    • 3-4 years -Utilization management experience, and -5-7 years -Diverse clinical experience required, and -1-2 years -2 years Supervisory experience required. -
    • Active DC RN License required.
    • CCM - Certified Case Manager -achievement within 2 years of assuming the Manager position required. -
      This position has a hiring range of $100,588 - $180,419
      
      

Keywords: MEDSTAR HEALTH, Silver Spring , Nurse Manager Utilization Management (RN) - Relocation Offered!, Executive , Washington, Maryland