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RN UM Care Management Coordinator

PhiladelphiaIndependence Blue Cross LLC


We currently have an opening for a Care Management Coordinator. This is a specialized UM Care Coordinator position with a specialization in neonatal intensive care (NICU).

DUTIES AND RESPONSIBILITIES:

  • Performs utilization management for NICU admissions either by telephonic, onsite, or electronic me
    ans.
  • Using the medical software criteria, establishes the appropriate level of care NICU/newborn care for continued stay.
  • Directs the delivery of care to the most appropriate setting, while maintaining quality.
  • Contacts attending physicians or NICU staff regarding treatment plans/plan of care and clarifies medical need for continued inpatient care at appropriate NICU or newborn care level.
  • Identifies inpatient admissions no longer meeting criteria for NICU or transitional level of care and refers care to plan Medical Directors for evaluation.
  • Presents cases to Medical Directors that do not meet established criteria and provides pertinent information regarding member’s medical condition and the potential home care needs.
  • Performs early identification of hospitalized members to evaluate discharge planning needs.
  • Collaborates with hospital case management staff, physician and family to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.
  • Identifies and refers cases for case management.
  • Identifies quality of care issues including delays in care.
  • Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated.
  • Maintains the integrity of the system information by timely, accurate data entry. Utilization decisions are in compliance with state, federal and accreditation regulations.
  • Ensures that all key functions are documented via Care Management and Coordination Policy.
  • Works to build relations with all providers and provides exceptional customer service.
  • Reports potential utilization issues or trends to designated manager or senior care coordinator and recommendations for improvement.
  • Is comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable.
  • Performs additional related duties as assigned.

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