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Independence Blue Cross · 19 hours ago

Care Management Coordinator RN (Acute UM) - Remote (PA/NJ/DE)

United States

Full-time

Remote

Mid Level

3+ years exp

Independence Blue Cross is seeking a Care Management Coordinator RN to oversee and coordinate medical care for members, ensuring appropriate and cost-effective treatment. The role involves acting as a patient advocate, evaluating treatment plans, and collaborating with healthcare providers to facilitate quality care and discharge planning.

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Responsibilities

Evaluate proposed plans of treatment, as defined in the precertification requirements of the group plan

Using the medical criteria of InterQual and/or Medical Policy, establish the need for inpatient, continued stay and length of stay, procedures and ancillary services

Directs the delivery of care to the most appropriate setting, while maintaining quality

Contacts attending physicians regarding treatment plans/plan of care and clarifies medical need for inpatient stay or continued inpatient care

Identifies admissions no longer meeting criteria and refers care to plan Medical Directors for evaluation

Presents cases to Medical Directors that do not meet established criteria and provides pertinent information regarding member’s medical condition and the potential home care needs

Performs early identification of members to evaluate discharge planning needs

Collaborates with facility case management staff, physician and family to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting

Identifies and refers cases for case management and disease management

Identifies quality of care issues including delays in care

Appropriately refers cases to the Quality Management Department and/or Clinical Services Supervisor when indicated

Maintains the integrity of the system information by timely, accurate data entry

Utilization decisions are compliant with state, federal and accreditation regulations

Ensures that all key functions are documented via Care Management and Coordination Policy

Works to build relations with all providers and provides exceptional customer service

Reports potential utilization issues or trends to designated manager or clinical supervisor and recommendations for improvement

Participates in the process of educating providers on managed care

Open to new ideas and methods; creates and acts on new opportunities; is flexible and adaptable

Builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy

Performs additional job-related duties as assigned

Qualification

Licensed Registered NurseMedical management experienceMicrosoft Office proficiencyCritical thinkingOrganizational skillsInterpersonal skillsProblem solvingFlexibilityAdaptability

Required

Licensed registered nurse within state of PA

Minimum three years clinical experience or equivalent (Intensive Care, Trauma, Home Health a plus) required

Active PA Licensed Registered Nurse required

Strong problem solving and critical thinking abilities

Proficiency utilizing Microsoft Word, Outlook, Excel, Access, SharePoint, and Adobe programs

Excellent organizational planning and prioritizing skills

Ability to work independently and provide positive resolution of complex medical and interpersonal challenges

Highly professional interpersonal skills for internal and external contacts, particularly in situations where medical evaluations are in conflict with treating providers proposed treatment plans

Comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable

Builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy