V-Tech Solutions, Inc. is looking for an RN Case Manager to support our client. The qualified candidate will manage and coordinate care for members/enrollees to ensure cost-effective, high-quality services. Collaborating with interdisciplinary teams, the case manager will address psychiatric, psychosocial needs, ensuring member satisfaction and adherence to standards. Responsible for complex case management, pre-authorization, and pharmacy reviews aligned with NCQA guidelines and District of Columbia Contract requirements.

*4 days per week on-site in DC 1 day remote*

Key Responsibilities

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 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.
Provides face to face case management in the community, as the member/enrollee’s health necessitate.
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.
Enters authorization as appropriate to the program and sends the reviews to Medical Director as appropriate.

Qualifications

ADN, BSN, MSN, or CNL from an accredited School of Nursing required.
3-4 years Case Management experience required, 3-4 years Utilization Management or related experience required, 5-7 years diverse clinical experience required, and 3-4 years acute inpatient care clinical experience required.
Active DC RN License and Basic Life Support for Healthcare providers required.

V-Tech Solutions Inc.

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RN Case Manager