RN Care Management Coordinator

Immediate need for a talented RN Care Management Coordinator . This is a 03 months Contract opportunity with long-term potential and is Remote , but the candidate must be in PA, DE, NJ . Pay Range: $40.00/hr - $45.00/hr (employee benefits include health insurance, 401(k) plan, paid sick leave). Job ID: 25-94626 Key Responsibilities Apply critical thinking and judgement skills based on advanced medical knowledge to cases, utilizing specified resources and guidelines to make case determination. Utilize 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. Utilize the behavioral health criteria of InterQual, ASAM, and/or Medical Policy to establish the need for inpatient, continued stay, length of stay, procedures and ancillary services. Contact servicing providers regarding treatment plans/plan of care and clarify medical need for services. Review treatment plans/plan of care with provider for requested services/procedures, inpatient admissions or continued stay, clarifying behavioral health information with provider if needed. Identify and refer cases where the plan of care/services do not meet established criteria to the Medical Director for further evaluation. Perform early identification of members to evaluate discharge planning needs. Collaborate with case management staff or physician to determine alternative settings as needed and provide support to facilitate discharge to the most appropriate setting. Report potential utilization issues or trends to designated manager and provide recommendations for improvement. Appropriately refer cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated, including delays in care. Appropriately refer cases to Case and Disease Management. Ensure requests are covered within the member’s benefit plan. Ensure utilization decisions comply with state, federal and accreditation regulations. Meet or exceed regulatory turnaround time and departmental productivity goals when processing referral/authorization requests. Ensure that all key functions are documented in accordance with Care Management Coordination Policy. Maintain the integrity of the system information by timely, accurate data entry. Perform additional duties as assigned. Key Requirements and Technology Experience Minimum of three (3) years of medical/surgical experience. Active PA Licensed RN or compact license that includes PA. BSN preferred. Minimum of three (3) years of acute care clinical experience in a hospital or other health‑care setting. Prior discharge planning and/or utilization management experience is desirable. Our client is a leading Health Insurance industry and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration. Seniority level Not Applicable Employment type Contract Job function Health Care Provider Industries Hospitals and Health Care Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. #J-18808-Ljbffr Pyramid Consulting, Inc