Utilization Care Manager Jobs in Reston, VA (NOW HIRING)

Kids Are Our Everything.Department10514 HSCSN - Care ManagementPay Range$65,124.80 - $108,555.20Under the direction of the Supervisory Care Manager, the Care Manager I (CMI) is responsible for providing comprehensive care coordination services to members who are enrolled in the Health Services for Children with Special Needs (HSCSN) health plan. The CMI routinely communicates with members on their assigned caseload to assess their needs; develop, monitor and evaluate treatment plan progress; and assist with coordinating care and referring to appropriate services for members who have moderate to complex medical and psychosocial needs.Minimum EducationMaster's Degree (Required)Minimum Work Experience2 years Two or more years of healthcare or related experience in managed care and /or care management (Preferred)2 years Two or more years experience in clinical or community resource settings (Preferred)Required Skills/KnowledgeEffective verbal and written communication skillsBilingual (Spanish speaking) preferredFamiliar with medical terminologyProficiency with computer systems and applications, particularly in Microsoft Office suiteStrong organizational skillsAbility to interpret and apply departmental requirementsAbility to make sound decisions and use good judgmentAbility to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer serviceAbility to participate in professional, multidisciplinary meetings to include internal and external staff meetingsRequired Licenses and CertificationsGraduate Social Worker Licensed in DC as a Licensed Graduate Social Worker (LGSW) (Required) Certified Case Manager (Preferred)Job FunctionsManages a caseload as outlined by CASSIP and Care Management Leadership.Maintains compliance in accordance with contractual and care management requirementsContacts enrollee at predetermined intervals based on stratification level or more frequently, as needed.Conducts face-to-face visits at a frequency determined by the enrollee’s assigned stratification level or more if needed, with each enrollee/caregiver in their homes, physician’s offices, or other mutually agreed upon locations.Assesses enrollees on enrollment and at intervals determined by the enrollee’s stratification level to identify needs/barriers and close gaps in care.Identifies over/under utilization promptly, and takes appropriate action according to organizational policy.Upon gathering health and mental/behavioral health, environmental, psychosocial and educational information, the CM develops, implements, and updates an accurate individualized comprehensive care plan for each assigned enrollee in collaboration with the PCP and/or other multi-disciplinary team members including public agencies.Completes routine care coordination and care management activities with attention to quality, timeliness and in compliance with company policy and national standards.Consults with Senior Care Manager to review and prioritize cases, set objectives, identify, and report potential risk and utilization concerns.Seeks advice from Senior Care Manager or other designated person with expertise in specialty areas when necessary.Accurately and timely documents enrollee findings and interactions according to organizational policy.Receives supervision by licensed staff according to oversight guidelines.Understands and abides by HSCSN’s Confidentiality policy and procedure regarding enrollee specific information.Participates in disposition and discharge planning activities. Contributes to the discharge plan in a timely manner, taking into consideration enrollee/family/significant others and match to healthcare resources.Clearly communicates verbally and in writing.Assists/empowers caregivers or enrollees to participate in care of child /self.Assists assigned enrollees and their caregivers in understanding the importance of EPSDT and compliance with all health services. Strives to achieve target rate of compliance for preventive medical and dental services.Assists with scheduling and monitors the compliance of mental health/medical appointments. Follows department policies for identifying and reporting noncompliance, missed appointments, and other reportable incidents including communication to primary care provider or specialist.Applies advanced knowledge of conditions of target population/standard approaches to care management and care coordination to assigned enrollees.Attend multidisciplinary meetings as necessary, including off-site meetings with other involved agencies.Receives and reviews reports of visits by vendors or contracted providers to enrollees receiving services and facilitates coordination of follow-up care, as needed.Refers enrollee/caregiver to appropriate vendor(s) on DME/assistive technology use. Educates on medication administration, about their conditions, and techniques for self-management within the scope of license. Refer, as needed, to appropriate vendor for additional education.Assist enrollees in planning for transitions of care to include but not limited to transitioning from Early Intervention to DCPS; from pediatric to adult providers; transitioning out of HSCSN when the enrollee ages out or is disenrolled for any reason; from outpatient to inpatient or the reverse; and entering or exiting the custody of CFSA, DYRS or any type of institutional care.Enters authorizations for services requiring authorization by Care Management staff.Keeps abreast of changing strategies and trends in care coordination and care management.Uses communication skills which promote understanding and collaboration with enrollees and their families, HSCSN staff, providers and others.Positively presents accurate information about HSCSN to enrollees and their families, HSCSN staff, providers, coworkers and the community.Maintains professional, courteous and customer focused demeanor in all interactions.Demonstrates knowledge of medical terminology and health care delivery systems.Applies time management and organizational skills effectively.Other Job DutiesMay perform other duties in addition to those outlined in this job descriptionThe disclosed salary range includes the minimum and maximum rates within which Children’s National believes an individual’s base pay rate will fall for this position. It is not typical for an individual to be hired at or near the maximum of the pay range. The exact pay rate for this position will be based on a variety of factors in alignment with the Children’s National compensation philosophy. These factors are legitimate and non-discriminatory including, but not limited to, the current market conditions; organizational needs; the individual’s combination of prior work experience, level of education, knowledge, skills, and other qualifications. Children’s National is committed to providing a fair and competitive total rewards package to each of our employees. This base salary range does not include our comprehensive benefits package or any additional compensation for which this position may be eligible.Childrens National Hospital is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender, identity, or other characteristics protected by law. The “Know Your Rights” poster is available here: and the pay transparency policy is available here: Know Your RightsPay Transparency Nondiscrimination Poster.Please note that it is the policy of Children's National Hospital to ensure a “drug-free” work environment: a workplace free from the illegal use, possession or distribution of controlled substances (as defined in the Controlled Substances Act), or the misuse of legal substances, by all staff (management, employees and contractors). Though recreational and medical marijuana are now legal in the District of Columbia, Children's National and its affiliates maintain the right, in accordance with our policy, to enforce a drug-free workplace, including prohibiting recreational or prescribed marijuana. #J-18808-Ljbffr