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Pyramid Consulting, Inc · 2 months ago

Care Management Coordinator/RN

Philadelphia, PA

Full-time

Onsite

Mid Level

$44.50/hr - $45/hr

3+ years exp

Pyramid Consulting, Inc. is a leading company in the Health Insurance Industry, currently seeking a Care Management Coordinator/RN for a contract position. The role involves applying medical knowledge to manage care coordination and ensure compliance with regulations while collaborating with healthcare providers and case management staff.

ConsultingInformation TechnologyLegalProfessional ServicesSoftwareStaffing Agency

Growth Opportunities

H1B Sponsor Likely

Responsibilities

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

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

Qualification

Active PA RN LicenseNeonatal Intensive CareDischarge planning experienceUtilization management experienceMedical management experienceMicrosoft Office proficiencyCommunication skillsProblem solving skillsInterpersonal skillsOrganizational skillsTime managementTeam playerAdaptability

Required

Candidate must reside in the tri-state area (PA, DE, NJ) and should have active PA RN License

Minimum of three (3) years of Neonatal Intensive Care clinical experience in a hospital or other health care setting

Active PA Licensed RN

Preferred

BSN Preferred

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

Benefits

Health insurance (medical, dental, vision)

401(k) plan

Paid sick leave (depending on work location)

Company

Pyramid Consulting, Inc

Glassdoor4.2

Pyramid Consulting, a global leader in workforce and technology solutions, empowers individuals and organizations to transform and thrive in the most challenging and competitive markets.

Founded in 1996

Alpharetta, Georgia, USA

5001-10000 employees

https://pyramidci.com/

H1B Sponsorship

Pyramid Consulting, Inc has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (178)

2024 (112)

2023 (95)

2022 (62)

2021 (50)

2020 (117)