Care Management Coordinator

Pyramid Consulting, Inc; Philadelphia (Philadelphia County); On-site; 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 actively seeking a Care Management Coordinator for a 03+ months contract in Philadelphia, PA (Remote). The role focuses on clinical judgment, utilization management, and discharge planning within a health insurance setting.

The ideal candidate holds an active PA RN license, 3+ years of medical‑surgical experience, and proficiency with InterQual and related policies. Strong communication and teamwork are essential to succeed in this position.

Qualifications

• Valid PA RN license required.
• Minimum of three (3) years of Medical-Surgical clinical experience.
• Prior discharge planning and/or utilization management experience preferred.
• Exceptional communication, problem solving, and interpersonal skills.
• Ability to learn new systems and adapt to changing processes.

Responsibilities

• Applies advanced medical knowledge and guidelines to determine case suitability.
• Uses InterQual and Medical Policy to assess medical necessity of plans.
• Determines inpatient needs, continued stay, and LOS per criteria.
• Collaborates with providers to ensure appropriate care planning.
• Refers non-conforming cases to Medical Director for review.
• Supports discharge planning and alternate setting decisions.
• Documents all steps in care management policies and records.
• Identifies utilization issues and proposes improvements.

Skills

Exceptional communication

Problem solving

Interpersonal skills

Team player

Time management

Adaptability

Healthcare knowledge

Education

Active PA Licensed RN

BSN preferred

Tools

Microsoft Word

Outlook

Excel

SharePoint

Adobe products

Job description

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

Job ID:26-24129

Pay Range: $42 - $45/hour. 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
• Minimum of three (3) years of Medical Surgical clinical experience in a hospital or other health care setting.
• Prior discharge planning and/or utilization management, 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, colour, 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.