PA Licensed Case Manager

Job Summary

Evaluating members' clinical conditions, the remote Contract Case Manager / Utilization Manager will apply medical necessity criteria and collaborate with providers to ensure appropriate care transitions while residing in the PA, NJ, or DE area.

Key Responsibilities

• Apply medical necessity criteria using InterQual and Care Management guidelines to determine appropriate levels of care
• Conduct clinical reviews for inpatient stays, procedures, and ancillary services while communicating with providers to validate medical needs
• Identify discharge planning needs and collaborate with case management or physicians to support safe transitions

Required Qualifications

• Active PA RN license or Nurse Licensure Compact (NLC) including PA
• Must reside in PA, NJ, or DE
• Minimum 3 years of Medical/Surgical RN experience
• Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe
• Experience in Utilization Management and Case Management, particularly with discharge planning needs