Pennsylvania Licensed UM Care Manager

Job Summary

Seeking a Pennsylvania Licensed UM Care Manager, the full-time remote position will manage utilization reviews of health plan services, assess member barriers to care, and collaborate with healthcare providers to ensure effective service delivery.

Key responsibilities:

• Obtain and document necessary information to support requested levels of care while consulting with the health plan medical director on medical necessity
• Conduct clinical reviews for authorization requests using established criteria and document all activities in the care management tracking system
• Participate in interdisciplinary team conferences to discuss complex cases and determine appropriate discharge plans or service levels

Required qualifications:

• Minimum of 2 years of experience in clinical and/or case management nursing
• Minimum of 1 year of work-related experience in Utilization Management
• Experience with prior authorizations preferred
• Current Pennsylvania RN license or multistate license issued by a participating NLC state
• Case management certification or approved clinical certification preferred