Care Management Coordinator, RN - Infusion Therapy (Remote)Location: Remote
Department: Care Management & Coordination - Infusion Therapy Team
Required License: Active Pennsylvania Registered Nurse (RN) License
Position SummaryWe are seeking an experienced Registered Nurse to join our Infusion Therapy Care Management team as a Care Management Coordinator. In this fully remote role, you will review clinical documentation and medical records to determine the medical necessity of requested healthcare services while ensuring compliance with evidence-based guidelines, health plan policies, and regulatory requirements.
This position offers the opportunity to make a meaningful impact by partnering with providers, advocating for members, and helping ensure patients receive the appropriate level of care in the most effective setting.
Key Responsibilities- Review medical records, treatment plans, and clinical documentation to determine the medical necessity of requested services.
- Apply evidence-based criteria, including InterQual, Medical Policy, and Care Management guidelines to make utilization management decisions.
- Independently approve medically necessary services within established clinical guidelines.
- Collaborate with physicians and healthcare providers to obtain additional clinical information and clarify treatment plans when needed.
- Refer cases that do not meet established medical necessity criteria to the Medical Director for further clinical review.
- Evaluate inpatient admissions, continued stays, procedures, infusion therapies, and ancillary services for medical appropriateness.
- Identify discharge planning opportunities and collaborate with case management teams to facilitate safe and appropriate transitions of care.
- Serve as a clinical resource and patient advocate, helping members navigate the healthcare system and access appropriate services.
- Ensure all utilization management decisions comply with state, federal, and accreditation requirements.
- Maintain accurate and timely documentation within care management systems.
- Identify utilization trends, quality concerns, or delays in care and escalate findings as appropriate.
- Collaborate with Case Management, Disease Management, Quality Management, and other internal partners to coordinate member care.
- Meet departmental productivity, quality, and turnaround time expectations.
Qualifications- Active Pennsylvania Registered Nurse (RN) License required.
- Associate's or Bachelor's degree in Nursing.
- Experience in Utilization Management, Care Management, Case Management, Prior Authorization, or a related clinical nursing role.
- Experience using InterQual or other evidence-based medical necessity criteria preferred.
- Strong clinical assessment, critical thinking, and decision-making skills.
- Excellent communication and collaboration skills.
- Strong organizational skills with the ability to manage multiple priorities in a fast-paced environment.
- Proficiency with electronic medical records and Microsoft Office applications.
Preferred Qualifications- Experience supporting Infusion Therapy patients.
- Managed care or health insurance experience.
- Knowledge of CMS, NCQA, URAC, and other healthcare regulatory standards.
- Experience with discharge planning and care coordination.
