RN Care Managment Coordinator - Philadelphia, United States - IntePros

Description

Intepros seeks an RN Care Managmnt Coordinator to collaborate with one of our healthcare clients remotely. While the position is remote, candidates must reside in the tri-state area (PA, NJ, DE).

Job Summary:

The primary responsibility of the Behavioral Health (BH) Care Management Coordinator is to assess a member's BH condition by reviewing medical records, including medical history and treatment records, to determine the medical necessity for patient services. This involves advanced knowledge, independent analysis of medical records, and the application of appropriate medical necessity criteria. The BH Care Management Coordinator may directly interact with providers to gather additional BH information. They have the authority to authorize services deemed medically necessary based on their personal review, and for cases not meeting established criteria, they provide relevant information to the Medical Director for further review. The BH Care Management Coordinator cannot deny care for patients but can approve it. Additionally, they are responsible for maintaining regulatory compliance with federal, state, and accreditation regulations and act as patient advocates and resources for members navigating the behavioral health care system.

Key Responsibilities:

• Apply critical thinking and judgment skills based on advanced medical knowledge to make case determinations using specified resources and guidelines.
• Utilize resources such as InterQual, ASAM criteria, Care Management Policy, Medical Policy, and Electronic Desk References to determine the medical appropriateness of proposed plans.
• Contact servicing providers to clarify medical needs for services and review treatment plans.
• Identify cases not meeting established criteria and refer them to the Medical Director for further evaluation.
• Collaborate with case management staff or physicians to determine alternative settings and facilitate discharge to the most appropriate setting.
• Report potential utilization issues or trends and make recommendations for improvement.
• Ensure requests are covered within the member's benefit plan and compliant with regulations.
• Meet or exceed regulatory turnaround time and departmental productivity goals.
• Ensure all key functions are documented according to policy and maintain system information integrity through timely, accurate data entry.
• Perform additional assigned duties.

Qualifications:

Education:

• Active PA Licensed RN, BSN preferred.

Experience:

• Minimum of three (3) years of Behavioral Health clinical experience in a hospital or other healthcare setting.
• Prior Behavioral Health utilization management experience is desirable.
• Medical management/precertification experience preferred.

Knowledge & Skills:

• Exceptional communication, problem-solving, and interpersonal skills.
• Action-oriented with the ability to set priorities and obtain results.
• Team player with the ability to build rapport and problem-solve effectively.
• Open to change and adaptable.
• Respectful of diversity.
• Excellent organizational and planning skills.
• Proficient in Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances