Top 111 Rn Utilization Management Jobs in Fairfax, VA

RN Case Manager
MedStar Health —Washington, DC
- $89,065 - $162,801 a year
- Full-time
- Nursing
- Microsoft Excel
- RN License
RN In Hospital Transiton of Care Case Manager
MedStar Health —Washington, DC
- $89,065 - $162,801 a year
- Full-time
- Background check
- Nursing
- Microsoft Excel
Quick Apply
RN In Hospital Transition of Care Case Manager
MedStar Health —Washington, DC
- $89,065 - $162,801 a year
- Full-time
- Nursing
- Microsoft Excel
- Psychiatry
Quick Apply
Clinical Administrator (RN)
MedStar Health —Washington, DC
- $99,931 - $152,280 a year
- Weekends as needed
- Nursing
- Microsoft Excel
- RN License
RN Team Lead Utilization Review
MedStar Health —Clinton, MD
- $89,065 - $162,801 a year
- Full-time
- Hybrid work
- Nursing
- RN License
- Hospital
Quick Apply
Remote Triage Nurse
GPW Health Center Inc —Woodbridge, VA
- $25.75 - $32.62 an hour
- Full-time
- Remote
- Bilingual
- Nursing
- RN License
- Health savings account
- Paid holidays
Quick Apply
Registered Nurse (RN) Outpatient Behavioral Health
Inova Health System —Sterling, VA
- 8 hour shift
- Hybrid work
- Nursing
- RN License
- Computer literacy
- Wellness program
- Paid parental leave
Clinic Nurse
George Mason University —Fairfax, VA
- Part-time
- Nursing
- RN License
- BLS Certification
Nurse CARE Manager, Wellness Center & Case Management
Marriott International, Inc —Bethesda, MD
- $84,000 - $147,500 a year
- Full-time
- CPR Certification
- Nursing
- Medication administration
- Commuter assistance
- Paid parental leave
4d
Clinical Reviewer DC
Comagine Health —Washington, DC
- $93,000 - $104,000 a year
- Full-time
- Hybrid work
- RN License
- Writing skills
- Mid-level
- Paid parental leave
- Health insurance
Quick Apply
Transition of Care RN
CINQCARE —Washington, DC
- $76,794 - $94,000 a year
- Full-time
- Remote
- Nursing
- Skilled nursing facility
- RN License
- Mileage reimbursement
- Commuter assistance
Quick Apply
1d
Utilization Management Reviewer
Amerihealth Caritas —Washington, DC
- Overtime
- Nursing
- Microsoft Outlook
- RN License
- Paid holidays
- Health insurance
6h
Travel RN - Case Management/Utilization Review - Case Management
American Traveler —Arlington, VA
- $2,917 a week
- 8 hour shift
- Acute care
- Nursing
- RN License
Quick Apply
Telephone Triage Nurse
Virginia Cancer Specialists —Fairfax, VA
- Full-time
- Nursing
- RN License
- BLS Certification
- Profit sharing
- Paid holidays
6d
Special Operations Case / Nurse Case Manager Part-Time (National Capitol Region)
KBR —Alexandria, VA
- $49.31 - $54.64 an hour
- Part-time
- Nursing
- RN License
- Military
- AD&D insurance
- Health insurance
Field RN Case Manager
MedStar Health —Washington, DC
- $89,065 - $162,801 a year
- Full-time
- Nursing
- Management
- RN License
RN Supervisor, Appeals, Managed Care, UM
Centene —Washington, DC
- $75,300 - $135,400 a year
- Full-time
- Nursing
- RN License
- Mid-level
- Paid holidays
- Health insurance
7d
Nurse Case Manager
Battelle —Arlington, VA
- Full-time
- Hybrid work
- Nursing
- RN License
- BLS Certification
- Wellness program
- Health insurance
Oncology Nurse (RN) Navigator Gastrointestinal Cancer
Inova Health System —Falls Church, VA
- Full-time
- Nursing
- RN License
- BLS Certification
- Wellness program
- Health insurance
Registered Nurse (RN) Case Manager 1
Inova Health System —Leesburg, VA
- Part-time
- Nursing
- RN License
- BLS Certification
- Wellness program
- Paid parental leave

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RN Case Manager

MedStar Health -
Washington, DC

Apply Now

Job Details

Full-time
$89,065 - $162,801 a year

Qualifications

RN License
Managing patients as a nurse case manager
Utilization management
Decision making
Patient care
Resource utilization in healthcare
Negotiation

Full Job Description

About this Job:

General Summary of Position

Coordinates negotiates procures and manages care of our members/enrollees to facilitate cost effective care and members/enrollees satisfaction. Facilitates the continuum of care works collaboratively with interdisciplinary staff internal and external to the organization. Responsible for carrying a complex case management case load ownership of a case management program(s) pre- authorization reviews to provide Medically Necessary timely and quality health care services in the most cost-effective manner and pharmacy reviews per population served. This role would include the ability to meet memebers in their homes or various community settings. We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels.

Primary Duties and 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 develops and manages complex case management cases and develops individualized plans of care according to NCQA standards/ guidelines and the District of Columbia Contract.
Acts as a liaison to MedStar Family Choice contracted vendors to facilitate care. Identifies gaps in contracted services and develops a plan to access care.
Acts as an advocate while assisting members/enrollees to coordinate and gain access to medical psychiatric psychosocial and other essential services to meet their healthcare needs. Authorizes and monitors covered services according to policy.
Assists hospital case management staff with discharge planning if applicable. Makes recommendation to alternate tier of Case Management programs or level of care as acuity necessitate.
Attends and participates in MFC staff meetings Clinical Operations department meetings Special Needs Forums work groups District/ community agencies meetings etc. as assigned. Provides input completes assignments and shares new findings with other staff. 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.
Provides face to face case management in the community as the member/enrollee's health necessitate.
Demonstrates behavior consistent with MedStar Health mission vision goals objectives and patient care philosophy.
Demonstrates skill and flexibility in providing coverage for other staff.
For assigned Case Management program(s) develops strategies assessment(s) and evaluation/goal tools according to NCQA standards/ guidelines and District of Columbia Contract for the population served. Utilizes standards/ guidelines to manage and document interactions for the program (s). Responsible for verifying that assigned program utilizes up-to-date standards in the medical and behavioral health community for the population served. Keeps informed about disease processes treatment modalities and resources.
Identifies and reports potential coordination of benefits subrogation third party liability worker's compensation cases etc. Identifies quality risk or utilization issues to appropriate MedStar personnel.
Identifies inpatients requiring additional services and initiates care with appropriate practitioners.
Maintains current knowledge of MFC benefits and enrollment issues in order to accurately coordinate services.
Maintains timely and accurate documentation in the clinical software system per Clinical Operation department's policy.
Monitors utilization of all services for fraud waste and abuse.
Performs telephonic ACD line coverage for Clinical Operations' needs.
Enters authorization as appropriate to the program and sends the reviews to Medical Director as appropriate. Coordinates review decisions and notifications per policy NCQA standards/ guidelines and District of Columbia Contract for timely decision making.
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.

Minimal Qualifications
Education

Graduate of an accredited School of Nursing required and
Bachelor's degree preferred

Experience

1-2 years Case management experience required and
1-2 years UM or related experience required and
3-4 years Diverse clinical experience required

Licenses and Certifications

RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia and/or the State of Maryland based on work location(s) Upon Hire required and
CCM - Certified Case Manager Upon Hire preferred

Knowledge Skills and Abilities

Verbal and written communication skills. Ability to use computer to enter and retrieve data. Ability to create edit and analyze Microsoft office (Word Excel and PowerPoint) preferred.

This position has a hiring range of : USD $89,065.00 - USD $162,801.00 /Yr.

Apply Now

Refine Your Search

Rn Utilization Management jobs in Fairfax, VA

RN Case Manager

RN In Hospital Transiton of Care Case Manager

RN In Hospital Transition of Care Case Manager

Clinical Administrator (RN)

RN Team Lead Utilization Review

Remote Triage Nurse

Registered Nurse (RN) Outpatient Behavioral Health

Clinic Nurse

Nurse CARE Manager, Wellness Center & Case Management

Clinical Reviewer DC

Transition of Care RN

Utilization Management Reviewer

Travel RN - Case Management/Utilization Review - Case Management

Telephone Triage Nurse

Special Operations Case / Nurse Case Manager Part-Time (National Capitol Region)

Field RN Case Manager

RN Supervisor, Appeals, Managed Care, UM

Nurse Case Manager

Oncology Nurse (RN) Navigator Gastrointestinal Cancer

Registered Nurse (RN) Case Manager 1

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