Remote Behavioral Health Case Manager (RN) – PA, NJ, DE

Case Manager – Behavioral Health

Location: Remote; candidates must reside in Pennsylvania, New Jersey, or Delaware

Licensure Requirement: Candidates must hold an active RN, LSW, LCSW, LPC, or LMFT license.

Position Overview

We are seeking an experienced Behavioral Health Case Manager to support behavioral health utilization management and care coordination. This individual will review clinical documentation and treatment plans to determine the medical necessity and appropriateness of behavioral health services using established clinical criteria, including InterQual and ASAM. The Case Manager will collaborate directly with behavioral health providers, physicians, and internal care management teams to obtain clinical information, facilitate appropriate levels of care, support discharge planning, and ensure members can effectively navigate the behavioral health care system. This position has the authority to approve services that meet established medical necessity criteria; cases that do not meet criteria are referred to the Medical Director for further review.

Key Responsibilities

• Review behavioral health medical records, treatment plans, and clinical documentation to determine medical necessity and appropriate level of care.
• Apply established clinical criteria, including InterQual, ASAM, Medical Policy, and Care Management guidelines, when evaluating services.
• Conduct utilization reviews for inpatient admissions, continued stays, procedures, and ancillary behavioral health services.
• Communicate with providers to obtain additional clinical information and clarify treatment plans or requested services.
• Approve services that meet established medical necessity criteria and refer cases that do not meet criteria to the Medical Director for determination.
• Identify discharge planning needs and collaborate with providers and care management teams to facilitate transitions to the most appropriate level of care.
• Identify members who may benefit from Case Management, Disease Management, or other care coordination programs.
• Serve as a member advocate and resource when navigating behavioral health services and the healthcare system.
• Identify and escalate potential utilization, quality, or delays-in-care concerns when appropriate.
• Verify requested services are covered under the member’s benefit plan.
• Ensure utilization management decisions comply with applicable state, federal, and accreditation requirements.
• Meet established turnaround times and departmental productivity expectations for referrals and authorization requests.
• Maintain complete, accurate, and timely documentation within care management systems.

Qualifications

Required:

• Active RN, LSW, LCSW, LPC, or LMFT license.
• Minimum of 3 years of behavioral health clinical experience within a hospital, health plan, behavioral health organization, or other healthcare setting.
• Strong clinical judgment and ability to independently evaluate behavioral health documentation.
• Excellent communication, organizational, problem-solving, and time-management skills.
• Ability to collaborate effectively with providers, physicians, members, and multidisciplinary teams.

Preferred:

• Previous Behavioral Health Utilization Management / Utilization Review experience.
• Experience with precertification, prior authorization, or medical management.
• Experience utilizing InterQual and/or ASAM criteria.
• BSN for RN candidates.
• Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and related healthcare technology systems.