*Candidate must live in MD, Washington D.C., VA, or PA.

Summary:

This position is responsible for evaluating the quality, effectiveness, timeliness, and appropriateness of facility-based care. Facility-based care includes inpatient hospital, skilled nursing care, rehabilitation, sub-acute, and inpatient hospice. The incumbent is responsible to facilitate the timely provision of care to members for appropriate utilization of health care resources using approved medical criteria and to facilitate timely discharge in conjunction with facility staff.

About Maryland Care Management, Inc. (MCMI)

Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care’s (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD’s largest Medicaid-managed care organizations.

Why join us?

MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans.

Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed. We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members’ lives.

What You’ll Do:

• Review members’ facility medical records and conduct concurrent reviews to assess the appropriateness of facility-based care, including abstracting appropriate clinical information.
• Communicate with the Medical Director, the attending, primary care physicians, hospital case managers, discharge planners, and other facility staff on an ongoing basis.
• Participate in patient conferences, family conferences, regular staffing for in-patient admissions, UM, and Case Management Rounds as indicated.
• Function as liaison and problem solver for all Concurrent review-related issues.
• Gather and report pertinent data, including quality and utilization indicator information and other applicable information.
• Identify and refer members to case management, disease management, and other programs to assist the member in accessing appropriate health care services.
• Participate in Transition of Care Activities to avoid readmissions.

Secondary Functions:

• Conduct provider and support system education on a routine basis.
• Refer cases of possible quality deviation to the Quality Management Department and possible over/under utilization to the Medical Director.
• Assist in orientation of new members.

Knowledge and Skills:

• Demonstrated written and verbal communication skills to include presentations and training before small and large groups.
• Demonstrated proficiency with Microsoft Office 365.

Education and Work Experience:

• Registered Nurse (RN) License in Maryland
• Three (3) years clinical/hospital nursing experience (such as ICU, medical/surgical, OB/maternity, etc.).
• Two (2) years Utilization Management/Utilization Review experience.

Preferred Education and Experience: 

• Bachelor’s of Science in Nursing (BSN)
• Minimum of one (1) year experience in Managed Care/Medicaid/insurance environment

EEOC Statement: 

Following applicable federal, state, and local laws, MCMI prohibits discrimination in employment based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other characteristic protected by law. This commitment extends to all aspects of employment, including hiring, promotion, compensation, benefits, training, social and recreational programs, and all other conditions and privileges of employment. 

As a healthcare organization, we recognize the vital importance of inclusivity in delivering quality care to our patients. We strive to foster an environment where individuals of all backgrounds feel respected, valued, and supported. We aim to better comprehend the unique needs of our patients and provide healthcare services that are culturally competent and sensitive. 

We encourage candidates from all backgrounds to apply and join us in our mission to provide compassionate and inclusive healthcare. We believe that a diverse workforce enriches our organization and allows us to better understand, connect with, and serve our diverse patient population.