Job Description

Immediate need for a talented RN Care Management Coordinator. This is a 03 months Contract opportunity with long-term potential and is located in PA, DE, NJ(Remote). Please review the job description below and contact me ASAP if you are interested.

Job Diva ID: 25-94789

Pay Range: $40 - $45 /hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

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, American Society of Addiction Medicine criteria (ASAM), Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
• Utilizes the behavioral health criteria of InterQual, ASAM 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 behavioral health 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 in accordance with Care Management Coordination Policy.
• Maintains the integrity of the system information by timely, accurate data entry.
• Performs additional duties assigned.

Key Requirements and Technology Experience:

• Active PA Licensed RN or compact license that includes PA
• BSN Preferred
• Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting
• Medical management/precertification experience preferred.
• Prior discharge planning and/or utilization management experience is desirable.

Our client is a leading Health Insurance Industry , and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

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