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

Independence Blue Cross is the leading health insurance organization in southeastern Pennsylvania. For 85 years, we have been enhancing the health and well-being of the people and communities we serve. We deliver innovative and competitively priced health care products and services; pioneer new ways to reward doctors, hospitals, and other health care professionals for coordinated, quality care; and support programs and events that promote wellness.

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. 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.

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