Care Management Coordinator/RN - 100% Remote

Care Management Coordinator/RN

Location: 100% Remote
Duration: 3+ Months (Possible Full-Time Conversion)

Position Overview

This is a 100% remote position. Candidates must reside in the tri-state area of Pennsylvania, Delaware, or New Jersey. An active Pennsylvania RN license or a Nurse Licensure Compact license that includes Pennsylvania is required.

This position will support the General Precertification Team, with streamlined training for PT/OT/ST requests and bariatric requests. Candidates must have Utilization Management experience in either an outpatient setting, particularly PT/OT, or an inpatient setting involving bariatric procedures or elective surgical procedures.

Job Summary

The Care Management Coordinator is responsible for evaluating members' clinical conditions through comprehensive review of medical records, including medical history and treatment records, to determine the medical necessity of requested services. The Coordinator applies advanced clinical knowledge, independent analysis, and established medical necessity criteria to make authorization determinations.

When additional clinical information is needed, the Coordinator communicates directly with providers to clarify treatment plans and obtain supporting documentation. The Care Management Coordinator has the authority to independently authorize medically necessary services based on their clinical review. Cases that do not meet established criteria are referred to the Medical Director for further review and determination. The Coordinator may approve services but does not deny care.

The role also requires maintaining compliance with applicable federal and state regulations and accreditation standards. The Care Management Coordinator serves as a patient advocate and resource, helping members access and navigate the healthcare system.

Key Responsibilities

The Care Management Coordinator applies critical thinking and clinical judgment based on advanced medical knowledge when reviewing cases. The Coordinator utilizes established resources and guidelines, including InterQual, Care Management policies, Medical Policies, and Electronic Desk References, to determine medical appropriateness.

The Coordinator uses InterQual and/or Medical Policy criteria to establish the need for inpatient services, continued stay, length of stay, procedures, and ancillary services. The Coordinator reviews medical records and treatment plans to determine whether requested services meet established medical necessity criteria.

The Coordinator contacts servicing providers to clarify treatment plans, obtain additional clinical information, and discuss the medical necessity of requested services. The Coordinator reviews treatment plans and plans of care with providers for requested services, procedures, inpatient admissions, and continued stays.

The Coordinator identifies cases that do not meet established criteria and refers them to the Medical Director for further evaluation and determination. The Coordinator performs early identification of members who may have discharge planning needs and collaborates with case management staff and physicians to identify alternative care settings and facilitate discharge to the most appropriate setting.

The Coordinator identifies and reports potential utilization issues and trends to management, along with recommendations for improvement. Cases are appropriately referred to Quality Management, Care Management and Coordination, Case Management, and Disease Management when indicated.

The Coordinator verifies that requested services are covered under the member's benefit plan and ensures utilization management decisions comply with applicable state and federal regulations and accreditation requirements. The Coordinator meets or exceeds regulatory turnaround times and departmental productivity standards when processing referral and authorization requests.

The Coordinator ensures all required activities and determinations are accurately documented in accordance with Care Management and Coordination policies. The role also requires maintaining accurate and timely system documentation and data entry and performing other duties as assigned.

InterQual Criteria

The Medical Affairs Utilization Management Department utilizes InterQual criteria as part of the case review process when required. InterQual criteria consist of objective clinical statements designed to support determinations regarding the medical appropriateness of proposed interventions. The criteria incorporate evidence-based standards of care, current clinical practices, and consensus from licensed specialists and/or primary care physicians. InterQual is used as a screening tool to support clinical rationale and decision-making.

Qualifications

An active Pennsylvania RN license is required, or the candidate must hold an active Nurse Licensure Compact license that includes Pennsylvania. A BSN is preferred. Candidates must have a minimum of three years of acute care clinical experience in a hospital or other healthcare setting. Prior discharge planning and/or Utilization Management experience is preferred. Medical management or precertification experience is also preferred. Experience in outpatient PT/OT Utilization Management or inpatient bariatric or elective surgical Utilization Management is strongly preferred.

Knowledge and Skills

The successful candidate will have excellent communication, problem-solving, interpersonal, critical-thinking, and clinical decision-making skills. The candidate should be action-oriented, able to establish priorities, and capable of achieving results in a fast-paced environment. Strong teamwork and the ability to build effective interdepartmental relationships are essential.

The candidate must be flexible and adaptable to changing priorities, processes, and technology and demonstrate respect for a diverse workforce and colleagues. Excellent organizational, planning, prioritization, and time-management skills are required. Knowledge of current trends and practices in healthcare and medical management is preferred.

Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe applications is required, along with the ability to learn and effectively utilize new systems and technologies as technology evolves.

Benefits and Compensation

We offer a competitive compensation package with a pay rate of $42-$45 per hour, commensurate with experience. Eligible full-time employees may receive medical, dental, and vision insurance, as well as life insurance, short-term disability, long-term disability, and other applicable benefits.