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    Care Management Coordinator RN - Philadelphia, United States - Independence Blue Cross

    Independence Blue Cross
    Independence Blue Cross Philadelphia, United States

    1 week ago

    Default job background
    Description

    Care Management Coordinator RN (remote)

    Company: [Company Name]



    RESPONSIBILITIES:

    • Evaluates a member's clinical condition through the review of medical records to determine the medical necessity for patient's services
    • Independently authorizes services deemed medically necessary after a personal review
    • Interacts with providers for additional clinical information
    • Provides relevant medical condition information to the Medical Director for further review if cases do not meet established criteria
    • Acts as a patient advocate and helps members navigate the healthcare system

    Key Responsibilities:

    • Applies critical thinking and judgement skills based on advanced medical knowledge to make case determinations
    • Utilizes specified resources and guidelines to determine medical appropriateness
    • Contacts providers regarding treatment plans and clarifies medical needs for services
    • Collaborates with case management staff or physician for discharge planning needs
    • Reports potential utilization issues along with recommendations for improvement
    • Ensures utilization decisions are compliant with regulations
    • Documents key functions and maintains system integrity through accurate data entry
    • Performs additional assigned duties

    Qualifications:

    Education: Active PA Licensed RN BSN Preferred

    Experience: Minimum of three (3) years of acute care clinical experience, prior discharge planning and/or utilization management experience 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; open to change; embraces diversity; excellent organizational planning and prioritizing skills; proficient in various software



    REQUIRED SKILLS:

    This role is designated by the company as fully remote within the Tri-State Area of Delaware, New Jersey, or Pennsylvania.



    About the Company:

    The company is an Equal Opportunity Employer committed to diversity and inclusion, providing opportunities for minorities, females, veterans, individuals with disabilities, and individuals of all sexual orientations and gender identities.

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