Utilization Management RN

IntePros; Philadelphia (Philadelphia County); On-site; USD 49,000 - 80,000; Full time

Job summary

A leading healthcare organization seeks a Care Management Coordinator to ensure effective care transitions for patients needing post-acute services. This role involves utilization management and collaboration with healthcare teams to optimize patient outcomes and promote efficient resource use.

Qualifications

• Minimum of three years of acute care clinical experience required.
• Prior experience in discharge planning and utilization management is highly desirable.

Responsibilities

• Conduct utilization management reviews for inpatient admissions.
• Collaborate with hospital staff and families to develop discharge plans.
• Monitor utilization trends and provide recommendations.

Skills

Communication

Problem Solving

Critical Thinking

Care Coordination

Education

Registered Nurse (RN) license in PA, NJ, or DE

Bachelor’s degree in Nursing (BSN)

Tools

EMR systems

Medical necessity review criteria (InterQual, Milliman)

Job description

4 days ago Be among the first 25 applicants

Job Title: Care Management Coordinator (Post-Acute Care)

General Summary

The Care Management Coordinator plays a critical role in ensuring high-quality, cost-effective care transitions for patients requiring post-acute services. Under the direction of the Care Management and Coordination Supervisor, this role focuses on utilization management, discharge planning, and coordination of care to the most appropriate setting. The Care Management Coordinator collaborates closely with hospital utilization review teams, attending physicians, and patients and their families to optimize healthcare outcomes and promote efficient resource utilization.

Key Responsibilities

• Conduct telephonic or onsite utilization management reviews for inpatient admissions, ensuring medical necessity and appropriate length of stay.
• Utilize medical criteria software to determine the need for inpatient care and facilitate safe, timely transitions to alternative care settings.
• Engage with attending physicians to discuss treatment plans and clarify the medical necessity of inpatient stays.
• Identify hospital admissions that no longer meet inpatient criteria and escalate cases to Medical Directors for further evaluation.
• Collaborate with hospital case management staff, physicians, and families to develop and implement effective discharge plans.
• Facilitate early identification of patients requiring post-acute care services, ensuring a smooth transition to home health, rehabilitation, skilled nursing, or other appropriate settings.
• Refer patients to Case Management or Disease Management programs as needed to support ongoing care needs.
• Identify and report quality of care issues, delays in treatment, or gaps in services to the Quality Management Department or Care Management and Coordination Supervisor.
• Maintain accurate and timely documentation in compliance with state, federal, and accreditation regulations.
• Build and maintain strong relationships with healthcare providers and deliver exceptional customer service.
• Monitor utilization trends and provide recommendations for process improvements.
• Assist in educating providers on managed care best practices and guidelines.
• Perform additional duties as assigned.
  
  

Required Qualifications:

Education & Experience

• Registered Nurse (RN) with an active license in PA, NJ, or DE (required).
• Bachelor’s degree in Nursing (BSN) preferred.
• Minimum of three (3) years of acute care clinical experience in a hospital or healthcare setting.
• Prior experience in discharge planning, utilization management, or case management is highly desirable.
• Valid driver’s license and access to reliable transportation may be required for onsite hospital visits.
  
  

Skills & Competencies:

• Strong knowledge of post-acute care settings, managed care principles, and care coordination best practices.
• Excellent communication and interpersonal skills to engage effectively with physicians, hospital staff, patients, and families.
• Strong problem-solving and critical thinking abilities to assess patient needs and recommend appropriate care solutions.
• Ability to work independently while collaborating within a multidisciplinary team.
• Highly organized with strong attention to detail and documentation accuracy.
• Proficiency in EMR systems and medical necessity review criteria (e.g., InterQual, Milliman).
  
  

This position is an excellent opportunity for an experienced RN with a passion for care coordination and post-acute care management. If you thrive in a dynamic healthcare environment and are committed to improving patient outcomes through effective care transitions, we encourage you to apply.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  IT Services and IT Consulting

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