Care Management Coordinator at Independence Blue Cross LLC in Philadelphia, Pennsylvania

Job Description:

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our mission to enhance the health and well-being of the people and communities we serve.At Independence, everyone can feel valued, supported, and comfortable to be themselves. Ourcommitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

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.  


• Prior discharge planning and/or utilization management experience is desirable.  


• Driver’s License and access to automobile required.

Additional Skills Required:

• Exceptional communication skills on all levels.


• Problem solving ability


• Organized, demonstrated excellent team management skills


• Team Player