Care Management Coordinator/RN
Innova Solutions•Philadelphia, PA
•Remote
About The Position
Innova Solutions is hiring a full-time, three-month contract RN Case Manager for a remote position based in Philadelphia, Pennsylvania. The role applies advanced medical knowledge and critical-thinking skills to review cases and determine medical appropriateness using specified resources, criteria, and guidelines. The position also supports discharge planning, provider communication, referrals, and utilization oversight.
Requirements
- Active Pennsylvania nursing license or a Nurse Licensure Compact license that includes Pennsylvania.
- Prior authorization experience.
Responsibilities
- Apply critical thinking and judgment based on advanced medical knowledge to make case determinations using specified resources and guidelines.
- Use InterQual, Care Management Policy, Medical Policy, and Electronic Desk References to determine the medical appropriateness of proposed plans.
- Apply InterQual and/or Medical Policy criteria to assess the need for inpatient care, continued stay and length of stay, procedures, and ancillary services.
- Contact servicing providers about treatment plans or plans of care and clarify the medical need for services.
- Identify members early to evaluate discharge-planning needs.
- Collaborate with case management staff or physicians to determine alternative settings and support discharge to the most appropriate setting.
- Report potential utilization issues or trends to designated managers and recommend improvements.
- Refer cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated, including cases involving delays in care.
- Refer members appropriately to Case and Disease Management.
- Ensure requests are covered under the member’s benefit plan.
Benefits
- Medical and pharmacy coverage, based on eligibility.
- Dental and vision insurance.
- 401(k).
- Health savings account (HSA) and flexible spending account (FSA).
- Life insurance.
- Pet insurance.
- Short-term and long-term disability coverage.
- Accident and critical illness coverage.
- Pre-paid legal and identity theft protection.
- Sick time and other paid leaves as required by law.
- Employee Assistance Program (EAP).
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
