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Utilization Case Manager Jobs in Washington (NOW HIRING)

Inova

Registered Nurse Case Manager

Falls Church, VA · On-site

The RN Case Manager 1 provides discharge planning and continuity of care for assigned patients in ... Uses utilization management techniques to determine the medical necessity, appropriateness and ...

MedStar Health

RN Case Manager

Washington, DC · On-site

Identifies quality risk or utilization issues to appropriate MedStar personnel. * Identifies ... CCM - Certified Case Manager Upon Hire preferred Knowledge Skills and Abilities * Verbal and ...

Encompass Health

Case Manager II

Bowie, MD · On-site

Participate in utilization review process: data collection, trend review, and resolution actions. * Participate in case management on-call schedule as needed. Qualifications * License or ...

MedStar Health

RN Utilization Review

Clinton, MD · On-site

$89K - $162K/yr

About the Job **Must be local to the DC/MD region with acute Utilization Review RN experience ... CCM - Certified Case Manager preferred Knowledge Skills and Abilities * Excellent problem-solving ...

Medix

RN Case Manager

Washington, DC · On-site

$36.32 - $50/hr

Monitor utilization and take action according to policy. * Gather comprehensive health information ... Consult with Supervisory Care Manager on case priorities and utilization concerns. * Document ...

Inova

Registered Nurse (RN) Case Manager

Fairfax, VA

The RN Case Manager 1 provides discharge planning and continuity of care for assigned patients in ... Uses utilization management techniques to determine the medical necessity, appropriateness and ...

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Utilization Case Manager information

What is a utilization case manager?

A Utilization Case Manager is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They review patient cases, coordinate with healthcare providers, and ensure that treatments are in line with established guidelines and insurance requirements. Their goal is to optimize patient outcomes while managing costs and ensuring compliance with regulations. Utilization Case Managers often work in hospitals, insurance companies, or managed care organizations.

How does a utilization case manager typically collaborate with healthcare providers and insurance companies?

Utilization Case Managers play a key role in coordinating care between healthcare providers and insurance companies. They review patient cases to ensure that the recommended treatments are medically necessary and align with insurance policies. This often involves regular communication with doctors, nurses, and insurance representatives to gather information, clarify treatment plans, and advocate for appropriate patient care. Strong collaboration skills are essential, as Utilization Case Managers must balance the needs of patients with organizational guidelines while maintaining positive professional relationships.

What degree do I need for utilization review?

Utilization case managers typically need at least a bachelor's degree in healthcare, nursing, social work, or a related field. Some positions may require a master's degree or professional certification, such as a Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), to advance in the role or handle complex cases.

What are the key skills and qualifications needed to thrive as a utilization case manager?

To thrive as a Utilization Case Manager, you need a background in nursing or social work, strong analytical skills, and a solid understanding of healthcare regulations and insurance processes, often supported by RN licensure or certification in case management (e.g., CCM). Familiarity with utilization management software, electronic health records (EHRs), and payer authorization systems is essential. Excellent communication, critical thinking, and negotiation skills help facilitate collaboration among patients, providers, and payers. These skills ensure appropriate care delivery, cost management, and compliance with healthcare standards.

What is the difference between Utilization Case Manager vs Utilization Review Nurse?

AspectUtilization Case ManagerUtilization Review Nurse
CredentialsRN license, case management certificationRN license, certification in utilization review
Work EnvironmentCase management teams, hospitals, insurance companiesUtilization review departments, hospitals, insurance providers
Primary FocusCoordinating patient care, discharge planning, resource allocationAssessing medical necessity, reviewing patient records for appropriateness
Common UsageBroader case management roles, patient advocacySpecific review of medical necessity and insurance claims

While both roles require RN licensure and focus on patient care, the Utilization Case Manager primarily coordinates overall patient services and discharge planning, whereas the Utilization Review Nurse concentrates on evaluating the medical necessity of treatments for insurance purposes. Understanding these distinctions helps in choosing the right career path or job search focus.

What are popular job titles related to Utilization Case Manager jobs in Washington? For Utilization Case Manager jobs in Washington, the most frequently searched job titles are:
What job categories do people searching Utilization Case Manager jobs in Washington look for? The top searched job categories for Utilization Case Manager jobs in Washington are:
What cities in Washington are hiring for Utilization Case Manager jobs? Cities in Washington with the most Utilization Case Manager job openings:
Utilization Case Manager jobs near you

Registered Nurse Case Manager

The Arora Group

Bethesda, MD • On-site

Other

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 23 hours ago

Job description


Currently recruiting a Registered Nurse (RN) Case Manager to work the Directorate of Healthcare Operations (DHO) at Walter Reed National Military Medical Center, Bethesda, Maryland. Full-time, Monday - Friday between 7: 00AM and 4: 30PM. At WRNMMC, contract employees shall be required to work varying shifts (8 to 12 hours) weekdays in a two-week period. Scheduling is always based on the needs of the MTF and must be coordinated through the requisite department POC and MTF COR. The specific schedule for each two-week period will be provided one month in advance.
DUTIES OF THE REGISTERED NURSE CASE MANAGER (RN):
  • The contracted RN shall provide the following services and in strict compliance with standing orders and protocols set forth by the MTF and IAW JC guidelines to include, the following: Provide professional case management services at Walter Reed National Military Medical Center (WRNMMC) or Fort Belvoir Community Hospital (FBCH).
  • Function as a member of a multidisciplinary team to meet individual and family comprehensive health needs. Duties involve planning, coordinating, facilitating, and evaluating health care, serving as an advocate for patient options and services.
  • Utilize communication and available resources to promote quality and cost-effective outcomes, across the continuum of care.
  • Serves as a clinical case manager and patient advocate, providing advanced practice clinical, administrative, and organizational skills in managing the continuity, access, and provision of care services for complex and defined patients, to include catastrophic and end-of-life patient populations.
  • Responsible for identification and management of patients with targeted, high risk and high cost diagnoses.
  • Independently perform difficult and complex assessment, review, coordination, planning, monitoring, evaluation and analysis of cases.
  • Screen potential case management clients, following identification for appropriateness/benefit of case management services. Interviews and provides individual counseling, as needed.
  • Address services needed to optimize current health, psycho-social, spiritual status, and benefits of case management services.
  • As required, enter approved metrics, patient data, and clinical progress notes into a prescribed database.
  • Conduct comprehensive assessment of patients, to establish in detail and specificity, the nature of their care needs, as well as causal and contributing conditions and circumstances.
  • Conduct comprehensive clinical interviews with the patient and other family members, as warranted, and collects pertinent data from all involved health care agencies, medical providers and resource programs.
  • Participate in a multi-disciplinary team to develop a treatment plan to address all identified conditions and problems.
  • Identify psychosocial aspects of anticipated care needs, to identify potential barriers to optimal health, resource utilization, and methods for minimizing barriers.
  • Assist the patient and the family in developing, documenting, and implementing appropriate care plans, and accessing agencies and care providers.
  • Apply a holistic approach to address health care needs, in collaboration with all health team members, to include the patient and the patient's family, as warranted.
  • Serve as advocate for patients and their families, in obtaining services and support.
  • Serve as a senior nursing leader and advances the nursing profession in case management. Introduces innovative nursing techniques, practices, and approaches, in collaboration with health care providers, to identify, plan, assess, and coordinate care programs, designed to provide efficient, comprehensive, and cost effective service for case-managed patients, throughout the continuum of care.
  • Conduct training in nurse case management for professional and paraprofessionals personnel, within the medical treatment facility (MTF). Provide education, counseling, and clinical assistance, in advanced techniques, to nursing personnel, medical students, interns/residents, staff physicians, and administrators. Provide formal and informal consultation, briefings, and educational offerings.
  • Represent the case management service, on or before, a variety of committees, boards, agencies, and concerned groups, as directed.
  • Coordinate with a patient-focused multidisciplinary team of clinicians to develop timeline protocols and high quality, affordable health care for selected case-managed patients and beneficiaries, facilitating desirable patient outcomes.
  • Identify strategies to improve patient access, reduce administrative burdens for DOD beneficiaries, and improve the cost effectiveness for the civilian/military health care delivery system. Identify problems with health care access and utilization, in both the military and civilian sectors, and recommends alternatives to overcome difficulties.
  • Interface with local, state, and federal agencies in obtaining regulations, policy manuals, and handouts, developing procedural guidelines to provide access to available programs.
  • Ensure guidelines are in compliance with case management standards of practice.
  • Propose regulatory and administrative changes to resolve identified problems or concerns.
  • Coordinate patient care through a continuum and facilitate the achievement of optimal outcomes in relation to care, quality and cost effectiveness.
  • Maintain excellent patient assessment skills, use the nursing process as a basis for professional practice, and demonstrate proper preparation of patients for treatments and procedures, to include surgical interventions.
  • Prescribe and communicate treatment plans IAW established acceptable practices in established MTF policy and procedures and IAW JC guidelines. Telephone and in-person assessment/evaluation includes the determination of optimal time and location for patient management (ER, clinic, homecare) and follow-up care as required.
  • Collect and assess significant patient history information and performs all necessary patient teaching.
  • Demonstrate and adhere to peri-operative, infection control and safety policies and procedures used in the MTF and IAW JC guidelines.
  • Schedule referral appointments, arranges for procedures, and performs telephone followup, as appropriate.
  • Ensure compliance with standard of care and practice in accordance with all established policies, procedures, and guidelines used in the medical treatment MTF and IAW JC guidelines.
  • Provide care within ethical and legal boundaries.
  • Complete orientation and competency verification programs in accordance with unit guidelines.
  • Serve and participate in committees, functions and other meetings, when assigned.
  • Provide relevant and timely information, and assist with decision-making and process improvement.
  • Report to the Nurse Manager, and take direction from the charge nurse and house supervisor as required in maintaining a safe environment for staff and patient(s).
  • Participate in the orientation, training and evaluation of duty performance of newly assigned personnel, as appropriate, when required.
  • Participate in customer service initiatives and medical readiness activities designed to enhance health services, as required.
  • Document as directed, the disposition of referrals, MEPERS, EOM reports, and actively participate in weekly/bi-weekly medical management conferences and report any updates to the staff on practice guidelines. Follow a systematic process to identify patients in need of referrals. Report high risk, high cost, and difficult patient situations, to the Department Head as indicated. Provide orientation for other new to the role and/or the facility.
  • Maintain education specific to the department and certification requirements as necessary.
  • Document as directed, the Case Management (CM) workload and patient care plans, MEPRS, EOM reports, and actively participate in weekly case management patient care conferences. Follow a systematic process to identify patients for referral to Case Management. Report high risk, high cost, and difficult situations, to the Department Head as indicated. Provide orientation for Case Managers new to the role and/or the facility.
  • Maintain education specific to the department and certification requirements as necessary.
  • Serves as advisor and consultant regarding development, implementation, and management of the MTF healthcare UM/RM activities. Utilizes critical thinking skills to support, coordinate, and implement all aspects and stages of the UM/RM program, identifying patient care process improvements, through continual review of processes.
  • Utilizes critical thinking skills to support, coordinate, and implement all aspects and stages of the UM/RM program, identifying patient care process improvements, through continual review of processes.
  • Responsible for tracking and monitoring active duty cases admitted for behavioral health issues, alcohol and drug related issues, as well as traumatic brain injuries.
  • Entails coordination of clinical care and services for active duty services members, family members, and retirees covered by the Tricare Prime insurance benefit.
  • Case Management recipients may have experienced a catastrophic injury or have been newly diagnosed with a chronic illness requiring the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services.
  • Performance primarily in cubicle in Building 17B, but position will also require an office in Behavioral Health in Building 19.
QUALIFICATIONS OF THE REGISTERED NURSE CASE MANAGER (RN): Degree/Education:
  • Degree: Associates Degree of Nursing.
  • Education: Graduate from a college or university accredited by National League for Nursing Accrediting Commission (NLNAC), or The Commission on Collegiate Nursing Education (CCNE).
  • Certifications in addition to Basic Life Support (5.2.3): Possess one of the following certifications:
    • Commission for Case Manager Certification Certified Case Manager (CCM)
    • Certification of Disability Management Specialists Commission: Certified Disability Management Specialist (CDMS)
    • Association of Rehabilitation Nurses: Certified Rehabilitation Registered Nurse (CRRN)
    • American Board for Occupational Health Nurses Certified Occupational Health Nurse (COHN) or Certified Occupational Health Nurse-Specialist (COHN-S).
    • National Board for Certification in Continuity of Care: Advanced Certification in Continuity of Care (ACCC)
    • Commission on Rehabilitation Counselor Certification: Certified Rehabilitation Counselor (CRC)
    • American Nurses Credentialing Center Nurse Case Manager (RN-NCM)
    • National Academy of Certified Care Managers: Care Manager Certified (CMC)
  • Experience:
  • Referral Management/Utilization Management (RM/UM) experience.
  • Clinical subspecialty experience in Behavioral Health (2-5 years current experience).
  • Knowledge of sources for patient care data. Examples are: medical records via ESSENTRIS and CHCS, 24 hour nursing reports, logs, consults and computerized data, RMS.
  • Board Certification (5.2.6.4.4): See Exhibit 5
  • Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse as required in the TO.
  • COMPENSATION & BENEFITS:Competitive pay
  • 10 days paid time off per year plus 7 sick days per year
  • 10 paid Federal holidays
  • Health & Welfare allowance offsets the cost of health insurance, long and short-term disability, and life insurance
  • Dental and vision plans offered, 401(k)

ABOUT THE ARORA GROUP:
The Arora Group is an award-winning, Joint Commission-certified nationwide healthcare services company that, for almost 30 years, has provided medical care for the men and women who serve our country in the U.S. Armed Forces. Our mission is to provide world-class care and give our healthcare professionals opportunities to improve their skills, learn from the best, and serve the needs of active duty service members, their families, and veterans.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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