This job has closed.

Pyramid Consulting, Inc · 1 day ago

Care Management Coordinator/RN

United States

Full-time

Remote

Mid Level

$40/hr - $45/hr

3+ years exp

Pyramid Consulting, Inc. is a leading company in the Health Insurance industry, currently seeking a Care Management Coordinator/RN. The role involves applying medical knowledge and critical thinking to manage cases, determine medical appropriateness, and collaborate with healthcare providers for treatment plans.

ConsultingInformation TechnologyLegalProfessional ServicesSoftwareStaffing Agency

Growth Opportunities

H1B Sponsor Likely

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, 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

Position is remote - candidate must reside in the tri-state area (PA, DE, NJ)

Qualification

Medical/Surgical experienceAcute Hospital Utilization managementInterQual experienceCritical thinkingCollaboration

Required

Minimum of three (3) years of Medical/Surgical experience

Previous Acute Hospital Utilization management/ IQ experience

Benefits

Health insurance (medical, dental, vision)

401(k) plan

Paid sick leave (depending on work location)

Company

Pyramid Consulting, Inc

Glassdoor4.2

Pyramid Consulting, a global leader in workforce and technology solutions, empowers individuals and organizations to transform and thrive in the most challenging and competitive markets.

Founded in 1996

Alpharetta, Georgia, USA

5001-10000 employees

https://pyramidci.com/

H1B Sponsorship

Pyramid Consulting, Inc has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (178)

2024 (112)

2023 (95)

2022 (62)

2021 (50)

2020 (117)