Aug 11, 2020

RN Case Manager I (Utilization Management)

  • Children's National Medical Center
  • Washington, DC, USA

Job Description

RN Case Manager I (Utilization Management) - (200000KF)

Description

All nursing practice is based on the legal scope of practice, national and specialty nursing standards, Children's National Policies and Procedures, and in accordance with all applicable laws and regulations. The Professional Model of Care requires registered professional nurses to be responsible and accountable for their own practice. Children's National supports the development of RN relationships within the community; specifically those relationships associated with the health and well being of the community at large.

Qualifications

Minimum Education
Bachelor's Degree

Minimum Work Experience
5 years

Specific Requirements and Preferences
With at least three in clinical nursing. At least one year experience in Utilization Management with knowledge of utilization review criteria. Experience in one or more of the following areas: case management, designated/pediatric specialty (Required)

Functional Accountabilities

Professional Practice/Research
1. Participate in Shared Leadership.
2. Contribute to the MAGNET Journey of Children’s National.
3. Ensure that nursing practice is based on evidence of best practice.
4. Accountable for participating in the Nursing Division’s Performance Improvement process (division or unit level).
5. Participate in community activities.

Facilitates Efficient & Effective Utilization of Resources for Patients
1. Conduct timely clinical reviews drawing upon appropriate resources and apply nationally recognized criteria to support medical necessity of patient observation admission or inpatient admission and continued hospitalization.
2. Address treatment delay, potential and actual denials with the Attending physician and other relevant members of the healthcare team.

Coordinates Authorization for Reimbursement
1. Provide clinical reviews to third party payers and validates authorization or denial of services from them.
2. Document approved and denied services in STAR to facilitate meaningful data analysis.

Communicates Effectively
1. Communicate verbally and/or written e.g., email) with payers and healthcare team in a clear, timely, accurate and professional manner and/or organized in a professional format.

Safety
1. Speak up when team members appear to exhibit unsafe behavior or performance
2. Continuously validate and verify information needed for decision making or documentation
3. Stop in the face of uncertainty and takes time to resolve the situation
4. Demonstrate accurate, clear and timely verbal and written communication
5. Actively promote safety for patients, families, visitors and co-workers
6. Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

Organizational Accountabilities
Organizational Accountabilities (Staff)
Organizational Commitment/Identification

1. Anticipate and responds to customer needs; follows up until needs are met


Teamwork/Communication

1. Demonstrate collaborative and respectful behavior
2. Partner with all team members to achieve goals
3. Receptive to others’ ideas and opinions


Performance Improvement/Problem-solving

1. Contribute to a positive work environment
2. Demonstrate flexibility and willingness to change
3. Identify opportunities to improve clinical and administrative processes
4. Make appropriate decisions, using sound judgment


Cost Management/Financial Responsibility

1. Use resources efficiently
2. Search for less costly ways of doing things


Safety

1. Speak up when team members appear to exhibit unsafe behavior or performance
2. Continuously validate and verify information needed for decision making or documentation
3. Stop in the face of uncertainty and takes time to resolve the situation
4. Demonstrate accurate, clear and timely verbal and written communication
5. Actively promote safety for patients, families, visitors and co-workers
6. Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

Primary Location

: District of Columbia-Washington

Work Locations

: Sheikh Zayed Campus 111 Michigan Avenue Washington 20010

Job

: Nursing

Organization

: Patient ServicesRegular / Temporary: R (Regular)Position Status: FT - Full-TimeShift: DayWork Schedule: Monday - Friday 830am-5pm

Job Posting

: Mar 12, 2020, 9:11:09 AM