Location: Remote (must reside in PA, DE, or NJ)

Schedule: Monday–Friday, Day Shift

Compensation: Up to $45/hour

Employment Type: Full-time

About The Role

We’re seeking a highly skilled and compassionate Care Management RN with Acute Care and Utilization Management experience to join our remote team. In this role, you’ll evaluate clinical conditions, review medical records, and determine medical necessity for services using evidence-based criteria. You’ll collaborate with providers, advocate for patients, and ensure compliance with regulatory standards.

Responsibilities

• Clinical Review & Decision-Making:
• Apply critical thinking and advanced medical knowledge to evaluate cases using InterQual, medical policy, and care management guidelines.
• Determine medical appropriateness for inpatient admissions, procedures, and ancillary services.
• Communicate with providers to clarify treatment plans and medical necessity.
• Care Coordination & Advocacy:
• Identify discharge planning needs early and collaborate with case managers and physicians.
• Refer cases to Medical Director when criteria are not met.
• Ensure services align with member benefits and regulatory requirements.
• Compliance & Documentation:
• Maintain accurate documentation per Care Management and Coordination Policy.
• Meet regulatory turnaround times and productivity goals.
• Report utilization trends and refer cases to Quality Management or Disease Management as needed.
  

Required Skills & Knowledge

• Strong communication, problem-solving, and interpersonal skills
• Ability to prioritize, manage time effectively, and adapt to change
• Team-oriented with a collaborative mindset
• Proficient in Microsoft Word, Outlook, Excel, SharePoint, and Adobe
• Familiarity with current medical practices and trends
  
  

Qualifications

• Active RN license in Pennsylvania or Nurse Licensure Compact including PA
• BSN preferred
• Minimum of 3 years of Acute Care clinical experience in a hospital or healthcare setting
• Utilization Management or Care Management experience
• Prior discharge planning and/or utilization management, Interqual or Millman/Robert's experience is preferred
  
  

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