Location: Columbia, MD
Cap-Exempt H-1B Position — No lottery required
About this Job: **General Summary of Position** Coordinates negotiates procures and manages care of our members/enrollees to facilitate cost effective care and members/enrollees satisfaction. Facilitates the continuum of care works collaboratively with interdisciplinary staff internal and external to the organization. Responsible for carrying a complex case management case load ownership of a case management program(s) pre- authorization reviews to provide Medically Necessary timely and quality health care services in the most cost-effective manner and pharmacy reviews per population served.We recruit retain and advance associates with diverse backgrounds skills and talents equitably at all levels. **Primary Duties and Responsibilities** - Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations. - 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 a liaison to MedStar Family Choice contracted vendors to facilitate care. Identifies gaps in contracted services and develops a plan to access care. - 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. - Attends and participates in MFC staff meetings Clinical Operations department meetings Special Needs Forums work groups District/ community agencies meetings etc. as assigned. Provides input completes assignments and shares new findings with other staf