Job Description

Job Description

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

Job Diva ID: 26-00095

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: -

• Position is remote - candidate must reside in the tri-state area (PA, DE, NJ)
• 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.
• Note: InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required.
• IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians.
• IQ criteria are used as a screening tool to support a clinical rationale for decision making.
• 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.

Key Requirements and Technology Experience:

• Must have an active PA license or a Nurse Licensure Compact to include PA.
• This req will be for our General Precert team- training will be streamlined for PT/OT/ST requests and bariatric requests.

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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