Care Management Coordinator RN

3 weeks ago

Philadelphia, United States CareerBuilder Full time

Bring your drive for excellence, team orientation and customer commitment to Independence Blue Cross; help us renew and reimagine our business and shape the future of health care. Our organization is looking to diversify, grow, innovate and serve, and we are looking for committed, empowered learning-oriented people to join our team. If this describes you, we want to speak with you.
Job Summary
The Care Management Coordinator primary responsibility is to evaluate a member's clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for patient's services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, the Care Management Coordinator directly interact with providers to obtain additional clinical information. The Care Management Coordinator has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For those cases that do not meet established criteria, the Care Management Coordinator provides relevant information regarding members medical condition to the Medical Director for their further review and evaluation. The Care Management Coordinator has the authority to approve but cannot deny the care for patients. The Care Management Coordinator is also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, the Care Management Coordinator acts a patient advocate and a resource for members when accessing and navigating the health care system.
Key Responsibilities
Applies critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination. Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
Utilizes the medical criteria of InterQual and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services.
Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services.
Reviews treatment plans/plan of care with provider for requested services/procedures, inpatient admissions or continued stay, clarifying medical information with provider if needed.
Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation determination
Performs early identification of members to evaluate discharge planning needs.
Collaborates with case management staff or physician to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.
Reports potential utilization issues or trends to designated manager and recommendations for improvement.
Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated to include delays in care.
Appropriately refers cases to Case and Disease Management.
Ensures request is covered within the member's benefit plan.
Ensures utilization decisions are compliant with state, federal and accreditation regulations.
Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests.
Ensures that all key functions are documented via Care Management and Coordination Policy.
Maintains the integrity of the system information by timely, accurate data entry.
Performs additional duties assigned.
Qualifications
Education
Active PA Licensed RN
BSN Preferred
Experience
Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting. Prior discharge planning and/or utilization management experience is desirable.
Medical management/precertification experience preferred.
Knowledge, & Skills
* Exceptional communication, problem solving, and interpersonal skills.
* Action oriented with strong ability to set priorities and obtain results.
* Team Player - builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy.
* Open to change, comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable.
* Embrace the diversity of our workforce and show respect for our colleagues internally and externally.
* Excellent organizational planning and prioritizing skills.
* Ability to effectively utilize time management.
* Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances.
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.

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