Remote Care Management Coordinator (RN) – PA, DE, NJ, Compact

Remote | Tri-State Area (PA, DE, NJ) Short-Term Contract / Contract-to-Hire Opportunity Important Note: This position may be a short-term assignment with the potential to convert to contract-to-hire. Candidates must be comfortable with both a short-term engagement and a CTH arrangement.

Position Overview The Care Management Coordinator (RN) plays a critical role in evaluating members’ clinical conditions to determine the medical necessity of healthcare services. This role involves comprehensive medical record review, application of evidence-based medical necessity criteria, collaboration with providers, and close partnership with Medical Directors when additional clinical review is required.

The Care Management Coordinator is empowered to authorize medically necessary services, ensure regulatory compliance, and serve as a patient advocate, helping members navigate the healthcare system effectively.

Key Responsibilities Clinical Review & Medical Necessity Determination

• Conduct detailed reviews of medical records, including medical history and treatment documentation
• Apply advanced clinical judgment and independent analysis to determine medical necessity
• Utilize InterQual, Medical Policy, Care Management Policy, and Electronic Desk References to support utilization decisions
• Establish medical appropriateness for inpatient admissions, continued stays, length of stay, procedures, and ancillary services

Provider Collaboration & Escalation

• Communicate directly with servicing providers to clarify treatment plans and medical necessity
• Review plans of care and request additional clinical information as needed
• Refer cases that do not meet established criteria to the Medical Director for further evaluation
• Authorize care when criteria are met; escalate only when required (authority to approve but not deny care)

Care Coordination & Discharge Planning

• Identify members early for discharge planning needs
• Collaborate with case management staff and physicians to support discharge to the most appropriate level of care
• Refer members to Case Management, Disease Management, or Quality Management as appropriate

Compliance, Documentation & Performance

• Ensure utilization decisions comply with state, federal, and accreditation regulations
• Meet or exceed regulatory turnaround times and departmental productivity standards
• Maintain accurate, timely documentation in accordance with Care Management policies
• Ensure benefit coverage aligns with member benefit plans
• Identify and report utilization trends or potential issues, providing recommendations for improvement

Required Qualifications Education & Licensure

• Active Pennsylvania RN license required
  • Nurse Licensure Compact (NLC) including PA accepted
• BSN preferred

Experience

• Minimum 3 years of Medical/Surgical nursing experience
• Prior Acute Hospital Utilization Management experience
• Strong working knowledge of InterQual (IQ) criteria

Knowledge, Skills & Abilities

• Strong clinical judgment, critical thinking, and problem-solving skills
• Excellent verbal and written communication abilities
• Highly organized with strong time management and prioritization skills
• Collaborative team player with the ability to build strong cross-functional relationships
• Adaptable and open to change in a fast-paced environment
• Knowledge of current medical practice trends
• Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe tools
• Ability to learn new systems and adapt to evolving technology

Work Environment

• 100% Remote, candidates must reside in PA, DE, or NJ
• Full-time hours during standard business operations
• Collaborative, mission-driven healthcare environment