Care Management Coordinator

VOLT•Philadelphia, PA

8d•Onsite

About The Position

Volt is immediately hiring a Care Management Coordinator in Philadelphia, PA. As a Care Management Coordinator, you will apply critical thinking and judgment skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination. You will utilize resources such as InterQual, Care Management Policy, Medical Policy, and Electronic Desk References to determine the medical appropriateness of the proposed plan. You will use the medical criteria of InterQual and/or Medical Policy to establish the need for inpatient, continued stay, length of stay, procedures, and ancillary services. You will service providers regarding treatment plans/plan of care and clarify the medical need for services. You will review treatment plans/plan of care with providers for requested services/procedures, inpatient admissions, or continued stay, clarifying medical information with providers if needed. You will identify and refer cases where the plan of care/services are not meeting established criteria to the Medical Director for further evaluation and determination. You will perform early identification of members to evaluate discharge planning needs. You will collaborate with case management staff or physicians to determine alternative settings and provide support to facilitate discharge to the most appropriate setting. You will report on potential utilization issues or trends to designated managers and provide recommendations for improvement. You will appropriately refer cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated, including delays in care. You will appropriately refer to Case and Disease Management. You will ensure requests are covered within the member’s benefit plan. You will ensure utilization decisions are compliant with state, federal, and accreditation regulations. You will meet or exceed regulatory turnaround time and departmental productivity goals when processing referral/authorization requests. You will ensure that all key functions are documented via Care Management and Coordination Policy. You will maintain the integrity of the system information through timely, accurate data entry. You will perform additional duties as assigned.

Requirements

Must have an active PA license or a Nurse Licensure Compact to include PA.
Prior authorization experience.

Responsibilities

Apply critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination.
Utilize resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
Utilize 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.
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 physicians to determine alternative settings at times and provide support to facilitate discharge to the most appropriate setting.
Reports on potential utilization issues or trends to designated managers 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 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.