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About The Job
The Registered Nurse Case Manager (Hybrid Inpatient Utilization Review) plays a vital role in ensuring appropriate utilization of hospital resources and timely coordination of patient care. Working in a hybrid schedule (Monday‑Friday, 8:30 AM‑5:00 PM; two days onsite and three days remote), this position focuses primarily on inpatient utilization review, care coordination, and discharge planning for 5 to 6 hospitals. The RN Case Manager conducts comprehensive clinical reviews using InterQual criteria to determine medical necessity, facilitate appropriate levels of care, and support efficient patient coordination. The role requires close collaboration with physicians, interdisciplinary teams, and payers to ensure compliance with regulatory standards and to meet critical 72‑hour turnaround times for reviews and authorizations. The ideal candidate demonstrates strong analytical and communication skills, a solid understanding of utilization management principles, and proven success in managing concurrent reviews and discharge planning within an acute care setting.
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/or the District of Columbia Contract.
Assists hospital case management staff with discharge planning if applicable. Makes recommendations to alternate tier of Case Management programs or level of care as acuity necessitates.
Develops strategies, assessments and evaluation/goal tools for assigned Case Management programs according to NCQA standards/guidelines and District of Columbia Contract for the population served. Utilizes these standards/guidelines to manage and document interactions for the program(s).
Identifies and reports potential coordination of benefits, subrogation, third‑party liability, workers’ compensation cases, etc., and signals 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.
Monitors utilization of all services for fraud, waste and abuse.
Performs telephonic ACD line coverage for Clinical Operations' needs.
Participates in multi‑disciplinary quality and service improvement teams.
Minimal Qualifications
Graduate of an accredited School of Nursing required.
Bachelor's degree preferred.
Experience
1‑2 years case management experience required.
1‑2 years UM or related experience required.
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.
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 per year.