This job posting isn't available in all website languages

RN Care Management Coordinator- Utilization Review

Health & Clinical Services
753 Total Views

Under the direction of a designated Care Management and Coordination Supervisor, performs clinical review of hospital admissions, determining alternative settings when appropriate.  Works to add value to healthcare by encouraging efficient and high quality use of the healthcare delivery system.  Promotes timely and dynamic discharge planning to facilitate early discharge and refers cases to Case Management when indicated.  Efficiently collaborates with the hospital utilization review department, attending physicians and members/families as appropriate

  1. Performs utilization management for inpatient admissions either telephonically or via fax.
  2. Using the medical software criteria, establish the need for inpatient, continued stay and length of stay.
  3. Directs the delivery of care to the most appropriate setting, while maintaining quality.
  4. Contacts attending physicians regarding treatment plans/plan of care and clarifies medical need for inpatient stay or continued inpatient care
  5. Identifies inpatient admissions no longer meeting criteria and refers care to plan Medical Directors for evaluation.
  6. Presents cases to Medical Directors that do not meet established criteria and provides pertinent information regarding member’s medical condition and the potential home care needs.
  7. Performs early identification of hospitalized members to evaluate discharge planning needs.
  8. Collaborates with hospital case management staff, physician and family to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.
  9. Identifies and refers cases for case management and disease management. 
  10. Identifies quality of care issues including delays in care. Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Supervisor when indicated.
  11. Maintains the integrity of the system information by timely, accurate data entry. Utilization decisions are in compliance with state, federal and accreditation regulations.
  12. Works to build relations with all providers and provides exceptional customer service. 
  13. Reports potential utilization issues or trends to designated supervisor and recommendations for improvement.
  14. Participates in the process of educating providers on managed care.

Performs additional related duties as assigned

  • Registered Nurse/ BS preferred.
  • Minimum of three (3) years acute care clinical experience in a hospital or other health care setting.
  • Prior Discharge planning and/or utilization management experience is desirable.
  • Exceptional communication skills on all levels
  • Problem solving ability
  • Organized, demonstrated excellent team management skills
  • Team Player

About Our Company

Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.


At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations.  For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!

Equal Employment Opportunity

Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. 

Agency Disclaimer

All resumes submitted directly to an Independence Blue Cross employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process. 

Current Associates

Applying for a position? Click here to return to the internal career site.

Current Associates

My Profile

Create and manage profiles for future opportunities, and review prior submissions.

Go to Profile

Similar Listings

New Jersey

📁 Health & Clinical Services

Philadelphia, Pennsylvania

📁 Health & Clinical Services

Philadelphia, Pennsylvania

📁 Health & Clinical Services