What are the responsibilities and job description for the Care Management Coordinator - AHA - remote position at Independence Blue Cross?
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Position Summary:
This position is responsible for overseeing and coordinating medical care provided to members, ensuring that appropriate and cost-effective care is rendered. The Care Management Coordinator (CMC) maintains quality care standards and limits the member’s and client’s exposure to medically unnecessary and inappropriate treatment. The Care Management Coordinator acts as a patient advocate and a resource for members, when accessing the health care system.
Responsibilities Overview:
- Evaluate proposed plans of treatment, as defined in the precertification requirements of the group plan
- Using the medical criteria of InterQual and/or Medical Policy, establish the need for inpatient, continued stay and length of stay, procedures and ancillary services
- Directs the delivery of care to the most appropriate setting, while maintaining quality
- Contacts attending physicians regarding treatment plans/plan of care and clarifies medical need for inpatient stay or continued inpatient care
- Identifies admissions no longer meeting criteria and refers care to plan Medical Directors for evaluation.
- 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.
- Performs early identification of members to evaluate discharge planning needs.
- Collaborates with facility case management staff, physician and family to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting
- Identifies and refers cases for case management and disease management.
- Identifies quality of care issues including delays in care
- Appropriately refers cases to the Quality Management Department and/or Clinical Services Supervisor when indicated.
- Maintains the integrity of the system information by timely, accurate data entry.
- Utilization decisions are compliant with state, federal and accreditation regulations.
- Ensures that all key functions are documented via Care Management and Coordination Policy
- Works to build relations with all providers and provides exceptional customer service.
- Reports potential utilization issues or trends to designated manager or clinical supervisor and recommendations for improvement
- Participates in the process of educating providers on managed care
- Open to new ideas and methods; creates and acts on new opportunities; is flexible and adaptable.
- Builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy
- Performs additional job-related duties as assigned
Experience:
- Minimum three years clinical experience or equivalent (Intensive Care, Trauma, Home Health a plus) required
- Medical management/precertification experience preferred
- Oriented in current trends of medical practice
- Active PA Licensed Registered Nurse required
Skills:
- Strong problem solving and critical thinking abilities
- Proficiency utilizing Microsoft Word, Outlook, Excel, Access, SharePoint, and Adobe programs.
- Excellent organizational planning and prioritizing skills
- Ability to work independently and provide positive resolution of complex medical and interpersonal challenges
- Highly professional interpersonal skills for internal and external contacts, particularly in situations where medical evaluations are in conflict with treating providers proposed treatment plans
- Participates in the process of educating providers on managed care
- Comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable.
- Builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy
- Performs additional job-related duties as assigned
Education: Registered nurse, BSN Preferred
Salary : $65,000 - $82,300