RN Care Coordinator — Transition & Utilization Expert

Highmark Health; Pittsburgh (Allegheny County); On-site; USD 75,000 - 105,000; Full time

Job summary

Allegheny Health Network is seeking a registered nurse skilled in care management to coordinate patient transitions and optimize resource use across care settings in the Pittsburgh area.

The role emphasizes collaboration with a care team, documentation, and adherence to regulatory requirements. You will support pre-certifications, authorizations, and utilization review while promoting patient satisfaction and appropriate length of stay.

Qualifications

• Minimum Bachelor’s Degree in Nursing -OR- Bachelor’s Degree and Nursing Diploma -OR- 6 years of relevant experience in lieu of a degree.
• 3 years in a clinical nursing role
• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
• Preferred Nationally recognized Case Management Certification
• BSN LICENSES or CERTIFICATIONS Required None
• Preferred ACM Certification (Accredited Case Manager) - American Case Management Association - American Case Management Association Case Management - American Board of Occupational Health Nurses (ABOHN) and Certified Case Manager (CCM) Commission for Case Manager Certification (CCMC)

Responsibilities

• Assesses patient physical, psychosocial, and economic needs for transition of care planning to various care levels.
• Collaborates with the care team to develop and communicate the continuum of care transition plan.
• Documents, verifies, and validates data to monitor interventions and outcomes.
• Interviews and collects patient data; performs chart review related to readmission.
• Obtains pre-certifications and authorizations from payers and places patients at appropriate care level.
• Supports urgent/continued stay and post-acute authorizations per regulatory and contractual requirements.
• Documents and reports clinical denials/appeals and analyzes denial trends with teams.
• Maintains knowledge of care management, utilization review, and policy changes; educates staff.
• Follows HIPAA and privacy policies; communicates with outpatient providers to enhance continuum of care.
• Engages in ongoing education and professional growth; performs other duties as assigned.

Skills

Critical thinking

Communication skills

Collaboration

Flexibility

Education

Bachelor’s Degree in Nursing

Nursing Diploma

Job description

Allegheny Health Network is seeking a registered nurse skilled in care management to coordinate patient transitions and optimize resource use across care settings in the Pittsburgh area.

The role emphasizes collaboration with a care team, documentation, and adherence to regulatory requirements. You will support pre-certifications, authorizations, and utilization review while promoting patient satisfaction and appropriate length of stay.