(RN) Case Manager

MedStar-posted 3 months ago

$89,065 - $162,801/Yr

Full-time • Mid Level

Hybrid • Baltimore, MD

Administrative and Support Services

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Medstar is seeking a dedicated RN Case Manager to join our Clinical Operations Team. This role involves utilizing case management skills to evaluate moderate to highly complex cases, acting as a liaison between providers and insurance entities to ensure quality, cost-effective, patient-centered care. The ideal candidate will have a strong clinical background in chronic conditions, understand the authorization process, and have experience with complex case management and care coordination. Strong telephonic skills are essential, and familiarity with Medicaid case management is a plus. This hybrid position operates Monday to Friday, 8:30 am to 5 pm, with 2 days in the office and 3 days remote, transitioning from the King Ave, Baltimore office to the Columbia office in December 2025.

Contribute to the achievement of established department goals and objectives and adhere to department policies, procedures, quality standards, and safety standards.
Comply with governmental and accreditation regulations.
Develop and manage complex case management cases and individualized plans of care according to NCQA standards/guidelines.
Act as a liaison to MedStar Family Choice contracted vendors to facilitate care.
Identify gaps in contracted services and develop a plan to access care.
Advocate for members/enrollees to coordinate and gain access to medical, psychiatric, psychosocial, and other essential services.
Authorize and monitor covered services according to policy.
Assist hospital case management staff with discharge planning.
Make recommendations to alternate tiers of Case Management programs or levels of care as acuity necessitates.
Attend and participate in various meetings and forums as assigned.
Provide face-to-face case management in the community as needed.
Demonstrate behavior consistent with MedStar Health mission, vision, goals, objectives, and patient care philosophy.
Develop strategies, assessments, and evaluation/goal tools according to NCQA standards/guidelines.
Maintain current knowledge of MFC benefits and enrollment issues.
Monitor utilization of all services for fraud, waste, and abuse.
Perform telephonic ACD line coverage for Clinical Operations' needs.
Participate in multi-disciplinary quality and service improvement teams.

Graduate of an accredited School of Nursing required.
Bachelor's degree preferred.
1-2 years of case management experience required.
1-2 years of UM or related experience required.
3-4 years of diverse clinical experience required.
Valid RN license in the District of Columbia and/or the State of Maryland based on work location(s) upon hire required.
CCM - Certified Case Manager upon hire preferred.

Experience in Medicaid case management.
Proficiency in Microsoft Office (Word, Excel, PowerPoint).

Competitive salary range of $89,065 - $162,801.
Hybrid work environment.

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