Post‑Acute Case Manager / Utilization Manager (Remote – Tri‑State Area)

Location: Remote (Candidate must reside in PA, NJ, or DE) Schedule: Monday–Friday, Day Shift Equipment: RN provides own equipment (Windows 10 or newer) Licensure Requirement: Active PA RN license or NLC license including PA

About the Role

The Case Manager / Utilization Manager evaluates members’ clinical conditions through comprehensive review of medical records to determine medical necessity, appropriate level of care, and compliance with medical policy and criteria. This role requires advanced clinical judgment, independent decision‑making, and the ability to authorize medically necessary services.

The Case Manager collaborates with providers, presents cases to the Medical Director when criteria are not met, ensures regulatory compliance, and serves as a patient advocate to support safe, timely, and appropriate care transitions.

Key Responsibilities

• Apply medical necessity criteria using InterQual, Medical Policy, and Care Management guidelines to determine appropriate level of care.

• Conduct clinical reviews for inpatient, continued stay, procedures, and ancillary services.

• Communicate with servicing providers to clarify treatment plans and validate medical need.

• Present cases not meeting criteria to the Medical Director for further evaluation.

• Identify discharge planning needs early and collaborate with case management or physicians to support safe transitions.

• Refer cases to Quality Management, Case Management, or Disease Management when indicated.

• Ensure requests align with member benefit plans and comply with federal, state, and accreditation regulations.

• Meet required turnaround times and productivity standards for authorization processing.

• Maintain accurate, timely documentation in accordance with Care Management & Coordination policy.

• Report utilization trends and recommend process improvements.

• Perform additional duties as assigned.

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 involving:

  • PT/OT/ST

  • Ambulance cases

  • Bariatric cases

• Experience coordinating discharge planning needs.

• Case Management experience in an Emergency Department preferred.

• BSN preferred.

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