Care Management Coordinator

Pyramid Consulting, Inc; Philadelphia (Philadelphia County); Remote; USD 58,000 - 62,000; Full time

Benefits offered by this job

Health insurance

401(k) plan

Paid sick leave

Job summary

Pyramid Consulting, Inc. is seeking a skilled Care Management Coordinator in Philadelphia, PA (Remote) for a 3+ month contract. The role requires RN licensure in PA, UM experience, and proficiency with InterQual criteria and care coordination processes.

You will collaborate with providers, review treatment plans, ensure regulatory compliance, and document outcomes. Strong communication, organizational, and tech skills (Word, Outlook, Excel, SharePoint, Adobe) are essential; healthcare benefits

Qualifications

• Active PA Licensed RN with current licensure.
• UM experience in outpatient or inpatient settings.
• Experience with InterQual or Milliman/Roberts criteria.
• Experience in chemotherapy, infusion centers, or prior auth.
• Strong communication and problem-solving skills.

Responsibilities

• Applies critical thinking and judgement based on medical resources to determine plan appropriateness.
• Uses InterQual criteria to establish the need for inpatient stays and services.
• Contacts providers to clarify treatment plans and medical necessity.
• Reviews plans of care with providers for requested services and admissions.
• Escalates cases where plans do not meet criteria to Medical Director.
• Identifies discharge planning needs early and coordinates alternatives.
• Documents utilization decisions and ensures compliance with regulations.

Skills

Active PA Licensed RN

UM experience (Outpatient/Inpatient)

InterQual/Milliman/Robert's experience

Chemotherapy/Infusion center exposure

Excellent communication and problem‑sl

Education

BSN preferred

Tools

Microsoft Word

Outlook

Excel

SharePoint

Adobe

Job description

Immediate need for a talented Care Management Coordinator. This is an 03+ months contract opportunity and is located in Philadelphia, PA (Remote).

Job Diva ID: 26-28447

Pay Rate: $42- $45/hr. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key 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, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
• Utilizes the medical criteria of InterQual and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services.
• Note: InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making.
• 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 medical 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 via Care Management and Coordination Policy.
• Maintains the integrity of the system information by timely, accurate data entry.
• Performs additional duties assigned.

Key Requirements and Technology Experience:

• Active PA Licensed RN
• BSN Preferred
• candidates will need to have UM experience either in Outpatient setting ( PT/OT) or Inpatient setting (bariatric or any surgical elective procedures).
• candidates must have outpatient experience, chemotherapy, office or infusion center. Best would be prior auth experience.
• InterQual or Millman/Robert’s experience is preferred.
• Exceptional communication, problem solving, and interpersonal skills.
• Action oriented with strong ability to set priorities and obtain results.
• Team Player - builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy.
• Open to change, comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable.
• Embrace the diversity of our workforce and show respect for our colleagues internally and externally.
• Excellent organizational planning and prioritizing skills.
• Ability to effectively utilize time management.
• Oriented in current trends of medical practice.
• Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances.

Our client is a leading Health Insurance Industry, and we are currently interviewing to fill this and other similar contract positions.

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.