Job Description

Care Management Coordinator

Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health.

Position Summary:

This position is responsible for overseeing and coordinating medical care provided to members, ensuring that appropriate and cost-effective care is rendered. The Care Management Coordinator (CMC) maintains quality care standards and limits the member's and client's exposure to medically unnecessary and inappropriate treatment. The Care Management Coordinator acts as a patient advocate and a resource for members, when accessing the health care system.

Responsibilities Overview:

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

Qualifications - External:

Experience:

• Licensed registered nurse within state of PA, BSN Preferred

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

Medical management/precertification experience preferred

Oriented in current trends of medical practice

Active PA Licensed Registered Nurse required

Skills:

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

Participates in the process of educating providers on managed care

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

Performs additional job-related duties as assigned

Fully Remote:

This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence's physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.

IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.

Job Tags

Similar Jobs