Care Manager

Currently seeking a Care Management RN . Please see details and qualifications below :

Position is remote - candidate must reside in the tri-state area (PA, DE, NJ)

M-F, day shift

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

Minimum of three (3) years of Acute Care clinical experience in a hospital or other health care setting.

Job Summary : The Care Management RN primary responsibility is to evaluate a member's clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for patient's services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, they will directly interact with providers to obtain additional clinical information. The Care Management RN has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For those cases that do not meet established criteria, they will provide relevant information regarding members medical condition to the Medical Director for their further review and evaluation. The Care Management RN has the authority to approve but cannot deny the care for patients. They are also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, they act as a patient advocate and a resource for members when accessing and navigating the health care system.

Responsibilities :

• Applies critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination. Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
• Contacts 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 physician to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.