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RN Precertification Care Management Coordinator - Part time

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Health & Clinical Services
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* Must be able to work 2 days per week 


Care Management Coordinator- Clinical Precertification

 

 Under the direction of a designated Care Management and Coordination Supervisor, performs telephonic/electronic reviews from providers and members for inpatient and outpatient services. Evaluates the planned procedure or treatment for medical appropriateness and setting as well as ensure application of benefit exclusion    

 

DUTIES AND RESPONSIBILITIES:

 

1.   Performs Clinical Precert reviews for inpatient admissions and outpatient services as well as coverage for a service or procedure.

2.   Using medical policy/medical software criteria and CMC policy as well as department guidelines for approvals, contacts attending physicians regarding treatment plans/plan of care and clarifies medical need for requested setting to obtain service.

3.   Refers cases to the medical director that do not meet established criteria or medical policy guidelines

4.   Performs early identification of hospitalized members to evaluate discharge planning needs.

5.   Maintains the integrity of the system information by timely, accurate data entry. Utilization decisions are in compliance with state, federal and accreditation regulations.

6.   Ensures that all key functions are documented via Care Management and Coordination Policy.

7.   Works to build relations with all providers and provides exceptional customer service. 

8.   Reports potential utilization issues or trends to designated manager or senior care coordinator and recommendations for improvement.

9.   Participates in the process of educating providers on managed care.

10.                Is comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable.

11.                Builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy.

12.                Performs additional related duties as assigned.


 


 

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

Education and experience:

Registered Nurse with active RN license in State of employment.  BS preferred.  Minimum of one year of acute care clinical experience in a hospital or other health care setting. 

Skills:

Exceptional communication, problem solving, and interpersonal skills; focused,  professionalism, action oriented with strong ability to set priorities and obtain results.       Organized, demonstrates excellent team management skills

            Team Player. Ability to effectively utilize time management.

 

 

Education and experience:

 

  • PA Licensed Registered Nurses required
  • BS Degree preferred 
  • Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting. 

Additional Skills Required:
  • 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. 

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