Care Management Coordinator (RN) - Infusion Therapy
Location: Remote
Department: Care Management & Coordination
Licensure: Active Pennsylvania RN license or Nurse Licensure Compact (NLC) license that includes Pennsylvania

Position Summary
We are seeking an experienced Registered Nurse to join the Infusion Therapy Care Management team. The ideal candidate will have clinical experience in an outpatient, chemotherapy, physician office, or infusion center setting, with prior authorization experience strongly preferred.

The Care Management Coordinator (CMC) is responsible for reviewing clinical information and medical records to determine the medical necessity and appropriateness of requested healthcare services. This position applies established clinical criteria and medical policies, communicates with providers when additional information is required, and ensures utilization management decisions meet regulatory and organizational requirements.

The CMC has the authority to approve services that meet established medical necessity criteria. Cases that do not meet criteria are escalated to the Medical Director for further review; the CMC does not issue clinical denials.

Key Responsibilities

• Review medical records, treatment plans, and clinical documentation to evaluate the medical necessity and appropriateness of requested services.
• Apply clinical guidelines and resources including InterQual, Medical Policy, Care Management Policy, and other established criteria to support utilization management decisions.
• Review requests related to infusion therapy and other procedures/services, ensuring appropriate clinical criteria are met.
• Communicate directly with physicians and other healthcare providers to obtain additional clinical information and clarify treatment plans when necessary.
• Independently authorize services that meet established medical necessity criteria and refer cases that do not meet criteria to the Medical Director for further determination.
• Verify requested services are covered under the member's benefit plan.
• Identify opportunities for case management, disease management, discharge planning, or alternative levels of care when appropriate.
• Identify and escalate potential utilization issues, delays in care, quality concerns, and trends requiring additional review.
• Maintain accurate and timely documentation of authorization requests, clinical reviews, decisions, and provider communications.
• Ensure utilization management activities comply with applicable state, federal, accreditation, and organizational requirements.
• Meet established turnaround times and departmental productivity expectations.
• Serve as a patient advocate and resource to members navigating the healthcare system.

Qualifications

• Active Registered Nurse (RN) license in Pennsylvania or an active Nurse Licensure Compact license that includes Pennsylvania.
• Clinical experience in an outpatient, chemotherapy, physician office, and/or infusion center environment.
• Prior authorization/utilization management experience strongly preferred.
• Experience reviewing medical records, treatment plans, and clinical documentation.
• Knowledge of InterQual and/or medical necessity criteria highly preferred.
• Strong clinical judgment, critical-thinking, and decision-making skills.
• Ability to communicate effectively with physicians, providers, members, and internal clinical teams.
• Strong documentation, organization, and time-management skills.
• Ability to work independently in a high-volume, deadline-driven environment.

Ideal Candidate Profile
The strongest candidate will be an RN with hands-on infusion or oncology/chemotherapy experience who has transitioned into prior authorization, utilization management, or clinical review. Someone who understands infusion therapies clinically and knows
how to review authorization requests against medical necessity criteria would be especially well aligned with this team.

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