What are the responsibilities and job description for the Care Management Coordinator RN position at IntePros?
Care Management Coordinator (RN)
Location: Remote (Candidates must reside in PA, DE, or NJ)
Licensure Requirement: Active Pennsylvania RN license or Nurse Licensure Compact (NLC) including PA
Position Overview
The Care Management Coordinator (RN) plays a critical role in evaluating members’ clinical conditions to determine the medical necessity of healthcare services. This position requires advanced clinical knowledge, independent judgment, and expertise in utilization management practices.
Through comprehensive review of medical records, including patient history and treatment plans, the Care Management Coordinator authorizes medically necessary services in accordance with established criteria and organizational policies. This role has the authority to approve care and commit financial resources on behalf of the organization; however, cases that do not meet criteria are escalated to the Medical Director for further review.
In addition, this role serves as a patient advocate, helping members navigate the healthcare system while ensuring compliance with all federal, state, and accreditation standards.
Key Responsibilities
Education & Licensure
This is an excellent opportunity for an experienced RN to leverage clinical expertise in a non-bedside role, contributing to high-quality, cost-effective care while advocating for patients and supporting healthcare outcomes at scale.
Remote
Location: Remote (Candidates must reside in PA, DE, or NJ)
Licensure Requirement: Active Pennsylvania RN license or Nurse Licensure Compact (NLC) including PA
Position Overview
The Care Management Coordinator (RN) plays a critical role in evaluating members’ clinical conditions to determine the medical necessity of healthcare services. This position requires advanced clinical knowledge, independent judgment, and expertise in utilization management practices.
Through comprehensive review of medical records, including patient history and treatment plans, the Care Management Coordinator authorizes medically necessary services in accordance with established criteria and organizational policies. This role has the authority to approve care and commit financial resources on behalf of the organization; however, cases that do not meet criteria are escalated to the Medical Director for further review.
In addition, this role serves as a patient advocate, helping members navigate the healthcare system while ensuring compliance with all federal, state, and accreditation standards.
Key Responsibilities
- Conduct thorough clinical reviews of medical records to determine medical necessity using established criteria and guidelines
- Apply evidence-based tools such as InterQual (IQ), Medical Policy, and Care Management policies to support decision-making
- Evaluate inpatient admissions, continued stays, procedures, and ancillary services for appropriateness and length of stay
- Collaborate directly with providers to obtain or clarify clinical information and discuss treatment plans
- Escalate cases that do not meet criteria to the Medical Director with comprehensive clinical summaries
- Identify discharge planning needs early and coordinate with care teams to facilitate safe and appropriate transitions of care
- Partner with case management and physicians to explore alternative care settings when appropriate
- Monitor and report utilization trends, delays in care, and opportunities for process improvement
- Ensure all determinations align with member benefit plans and regulatory requirements
- Meet or exceed turnaround time standards and productivity expectations
- Maintain accurate and timely documentation in accordance with departmental policies
- Refer cases to Quality Management, Case Management, or Disease Management programs as appropriate
Education & Licensure
- Active Registered Nurse (RN) license in Pennsylvania or compact state with PA coverage required
- Bachelor of Science in Nursing (BSN) preferred
- Minimum of 3 years of Medical/Surgical nursing experience
- Prior experience in Acute Care Utilization Management required
- Experience using InterQual (IQ) criteria strongly preferred
- Strong clinical assessment and critical thinking skills
- Excellent communication and provider engagement abilities
- Proven ability to work independently and make sound clinical decisions
- Highly organized with strong time management and prioritization skills
- Collaborative team player with the ability to build cross-functional relationships
- Adaptable and comfortable working in a fast-paced, evolving environment
- Knowledge of current medical practices and healthcare trends
- Proficiency with Microsoft Office Suite (Word, Excel, Outlook), SharePoint, and Adobe tools
- Ability to quickly learn and navigate new systems and technologies
This is an excellent opportunity for an experienced RN to leverage clinical expertise in a non-bedside role, contributing to high-quality, cost-effective care while advocating for patients and supporting healthcare outcomes at scale.
Remote