RN Care management Coordinator/Utilization Management RN

Company: Pyramid Consulting, Inc
Location: Philadelphia
Posted on: July 4, 2025

Job Description:

Job Description Immediate need for a talented RN Care management Coordinator/Utilization Management RN. This is a 03months contract opportunity with long-term potential and is located in Philadelphia, PA (Remote). Please review the job description below and contact me ASAP if you are interested. Job ID: 25-73981 Pay Range: $40.50 - $47.50/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location). Key Responsibilities: - Shift: First - Days: M-F - 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. - Utilizes the medical criteria of InterQual and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services. - Note: InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making. - 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. - Reports potential utilization issues or trends to designated manager and recommendations for improvement. - Appropriately refers cases to the Quality Management Department and/or Care - Management and Coordination Manager when indicated to include delays in care. - Appropriately refers cases to Case and Disease Management. - Ensures request is covered within the member’s benefit plan. - Ensures utilization decisions are compliant with state, federal and accreditation regulations. - Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests. - Ensures that all key functions are documented via Care Management and Coordination Policy. - Maintains the integrity of the system information by timely, accurate data entry. - Performs additional duties assigned. Key Requirements and Technology Experience: - Key Skills; Utilization Management, Discharge Planning, Post Acute - Active PA Licensed RN /Compact License - BSN Preferred - Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting. Prior discharge planning and/or utilization management experience is desirable. - Medical management/precertification experience preferred. - Exceptional communication, problem solving, and interpersonal skills. - Action oriented with strong ability to set priorities and obtain results. - Team Player - builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy. - Open to change, comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable. - Embrace the diversity of our workforce and show respect for our colleagues internally and externally. - Excellent organizational planning and prioritizing skills. - Ability to effectively utilize time management. - Oriented in current trends of medical practice. - Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances. Our client is a leading Health Insurance Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration. Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. 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Keywords: Pyramid Consulting, Inc, Catonsville , RN Care management Coordinator/Utilization Management RN, Healthcare , Philadelphia, Maryland