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RN Care Coordination Specialist
2 months ago
Company :
Highmark Health
Job Overview :
POSITION SUMMARY:
The RN Care Coordination Specialist is accountable for securing insurance precertification and recertification, acting as a liaison with insurance providers, conveying clinical details as required, and addressing any potential or actual denials. This role is integral to the care coordination team.
KEY RESPONSIBILITIES:
- Secures necessary pre-certifications and authorizations from insurance companies, ensuring proper placement in the appropriate care level prior to admission, adhering to medical necessity criteria and payer guidelines. (30%)
- Facilitates urgent and emergent authorizations, continued stay approvals, and post-acute service authorizations as required, while complying with all regulatory and contractual obligations. (30%)
- Documents, monitors, and resolves clinical denials and appeals; collaborates with care coordination teams, performance improvement teams, and physicians to develop action plans for denial trends. (30%)
- Maintains up-to-date knowledge of care management, utilization review updates, authorization protocols, and regulatory requirements. Acts as a resource for all staff regarding utilization review practices and payer guidelines. (5%)
- Adheres to hospital policies, procedures, and regulations set forth by federal and state authorities. (5%)
- Engages with outpatient providers through various communication methods to enhance the continuum of care.
- Takes responsibility for ongoing education and professional development.
- Performs additional duties as assigned.
QUALIFICATIONS:
Minimum Requirements:
- Bachelor's degree or equivalent experience as determined by the organization in lieu of a degree.
- Current Pennsylvania RN licensure.
- Nationally recognized Care Management Certification within five years of employment (three years for currently employed Utilization Review nurses).
- 2-3 years of nursing experience, including at least one year in Utilization Management.
Preferred Qualifications:
- Experience in case management, discharge planning, and/or familiarity with InterQual criteria.
Disclaimer: This job description is intended to provide a general overview of the position and does not encompass all duties and responsibilities that may be required.
Compliance Requirement: This position adheres to ethical and legal standards as outlined in the company's code of conduct and policies.
Compensation:
Pay Range Minimum: $28.18
Pay Range Maximum: $43.80
Compensation is determined by various factors including qualifications, experience, and expected contributions.
Equal Opportunity Employer: Highmark Health is committed to diversity and inclusion in the workplace and prohibits discrimination based on any protected status.
Accessibility: We strive to make our site accessible to all users. For assistance, please reach out to our HR Services.
Req ID: J248733
