Embedded Clinical Care Coordinator - Utilization//Pediatrics/InterQual

About the role

Please note: This will be an embedded position at a children's hospital in Wilmington, Delaware.

General Overview

Responsible for the implementation of effective utilization management strategies including: review of appropriateness of health care services, application of criteria to assure appropriate resource utilization, identification of opportunities for referral to a Care Coordinator (case management) and identification and resolution of quality issues.

Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.

Essential Job Functions

• Implements utilization management review processes that are consistent with established industry and corporate standards and are within the Clinical Care Coordinator's professional discipline. Effectively functions in accordance with applicable state, federal laws and regulatory compliance.
• Implements all reviews according to accepted and established criteria, as well as other approved guidelines and medical policies. Promotes quality and efficiency in the delivery of services.
• Respects the member's right to privacy, sharing only information relevant to the member's care and within the framework of applicable laws. Practices within the scope of ethical principles.
• Identifies and refers members whose healthcare outcomes might be enhanced by Care Coordination interventions. Employs collaborative interventions, which focus, facilitate and maximize the member's health care outcomes. Is familiar with the various care options and provider resources available to the member.
• Educates professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships. Develops and sustains positive working relationships with internal and external customers.
• Utilizes outcomes data to improve ongoing care management services.
• Serves as a subject matter expert to both internal and external sources (e.g. providers, regulatory agencies, UM and policy) to provide education, consultation and training when indicated. Serves as a resource to guide, mentor and counsel others in regards to understanding the drivers of health care costs to improve member outcomes related to Plan benefits and resources.
• Collaborates, coordinates and communicates with the member's treating provider(s) in more complex clinical situations requiring clinical and psychosocial intervention.
• Ensures all activities are documented and conducted in compliance with applicable business process requirements, regulatory requirements and accreditation standards that support all lines of business.
• Other duties as assigned or requested.

Minimum Qualifications

• Current DE/Compact RN license and/or additional states as required
• 2-5 years' experience in clinical setting
• Utilization Management experience
• Proficient InterQual experience

Additional information

Two (2) years of any combination of clinical, case management and/or disease/condition management, provider operations and/or health insurance experience

Preferred Qualifications

Certification in Utilization Management or related field

Certification in Case Management (CCM)

Five or more years of any combination of clinical, case management and/or disease/condition management, provider operations and/or health insurance experience

• Bachelor's Degree in Nursing (BSN)
• 2+ to 5 years experience
• Management Experience Required - No

Minimum Education - Certification

• Willingness to Travel - Occasionally
• SKILLS AND CERTIFICATIONS
• InterQual

Ideal Candidate

Nurse with a DE License, to possess 2 - 5 years of Pediatrics experience, Utilization Management experience and must have InterQual expeerience. This is an embedded position in a children's hospital

Additional Information

All your information will be kept confidential according to EEO guidelines.