Pyramid Consulting, Inc · 1 month ago
Care Management Coordinator/RN
United States
Full-time
Remote
Mid Level
$40/hr - $45/hr
3+ years expPyramid Consulting, Inc. is seeking a Care Management Coordinator/RN for a contract position with long-term potential. The role involves applying critical thinking and medical knowledge to manage care cases, collaborating with providers, and ensuring compliance with regulations.
ConsultingInformation TechnologyLegalProfessional ServicesSoftwareStaffing Agency
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, American Society of Addiction Medicine criteria (ASAM), Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan
Utilizes the behavioral health criteria of InterQual, ASAM and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services
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 behavioral health 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 in accordance with Care Management Coordination Policy
Maintains the integrity of the system information by timely, accurate data entry
Performs additional duties assigned
Qualification
Required
Minimum of three (3) years of Medical/Surgical experience
Previous Acute Hospital Utilization management/ IQ experience
Active PA Licensed RN or compact license that includes PA
Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting
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 in accordance with Care Management Coordination Policy
Maintains the integrity of the system information by timely, accurate data entry
Preferred
BSN Preferred
Medical management/precertification experience preferred
Prior discharge planning and/or utilization management experience is desirable
Benefits
Health insurance (medical, dental, vision)
401(k) plan
Paid sick leave (depending on work location)
Company
Pyramid Consulting, Inc
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.
5001-10000 employees
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)
Funding
Current Stage
Late StageLeadership Team
Ramesh Maturu
President and Co-Founder
Manish Kaushik
Chief Financial Officer
Recent News
2025-08-18
Company data provided by crunchbase