Utilization Management Director jobs in Washington, DC

MedStar Health is looking for a Director of Case Management and Utilization to join our team! We are looking for a registered nurse or social worker with the ability to demonstrate ethical behavior that supports the hospital’s mission, values, and commitment to compliance with all federal, state, and regulatory laws. Inspires trust and exhibits honesty and integrity within the scope of daily activities. 

The Director of Case Management and Utilization will develop, implement, and evaluate the strategic plan for the hospital-wide Case Management process. Provide operational supervision of case management department. Coordinate and support ongoing problem solving. Establish tools, processes, and systems to optimize the individual roles of the department. 

Join one of the largest healthcare systems in the Baltimore-Washington metro region, also recognized as one of the "Healthiest Maryland Businesses". Apply today and learn how MedStar Health can be your next great career move! 

 
Primary Duties: 

• Responsible for assuring compliance with hospital wide patient care quality monitoring in collaboration with the Performance Improvement Department. Assures performance improvement activities with ongoing monitors for the Case Management Department. Knowledge of the organization’s performance improvement priorities and outcomes. Assists the organization to achieve compliance in the Important Functions described in the Joint Commission.  

• Provides direct supervision of utilization management activities as mandated by State/Federal regulations. Assures utilization criteria and monitors are approved by Medical Staff as appropriate. Maintains the program to assure coordination of patient services and financial issues related to reimbursement for care provided with all Managed Care Companies and outside providers. Assist Utilization Management Committee Chairman to prepare for meetings and comply with regulatory requirements. Assures appeals system is maintained and will coordinate with the Business Office for maximum reimbursement.  

• A member of the Hospital Ethics Committee, the Clinical Pathways Committee, Medical Records Committee, and the Performance Improvement Committee. Implements changes and maintains systems for statistical reporting of Utilization Review activities and develops outcomes documentation and reporting as the Case Management program evolves. Maintains ongoing communication with staff on the nursing units to address concerns relative to Case Management issues. Responsible for ongoing education of medical staff, nursing, and other ancillary services effected by development of and changes to the Case Management program in keeping with the changing health care environment.  

• Assures ongoing communication with key departments/providers to assure negotiation/facilitation of patient movement through the health care system. Provides daily ongoing supervision of Case Managers and the Social Workers for case management problems direction and resolution. Plans and participates in staff development as appropriate. Responsible for personnel function of the Department including work performance and recommendations regarding personnel actions for professional and support staff.  

• Monitors and controls departmental utilization of hospital resources and makes recommendations to the Vice President of Professional Services regarding planned budgetary departmental needs and requirements. Maintains confidentiality in accordance with hospital policy. Communicates effectively and courteously with all patients, families, visitors, physicians, and hospital staff 

Qualifications:  

• Master’s degree in Health Administration, Business Administration, Science of Nursing or Social Work. 

• 5-7 years' experience in utilization management, discharge planning, quality management or case management. 

• 3-4 year’s clinical experience in an acute care setting. 

• Management experience. 

• Certification in Case Management required. 

• RN or Social Work Licensure in Maryland required.