Precertification RN (Remote – PA, NJ, DE)
Location: Remote (Candidate must reside in PA, NJ, or DE)
Licensure: Active PA RN license or NLC including PA
Team: Infusion Therapy
Schedule: Monday–Friday, Day Shift
Summary The Care Management Coordinator evaluates members’ clinical conditions through comprehensive review of medical records to determine medical necessity, level of care, and alignment with medical policy and criteria. This role requires advanced clinical judgment, independent authorization decision‑making, and direct collaboration with providers to obtain or clarify clinical information. The Coordinator may approve services but does not issue denials. They ensure regulatory compliance, support safe care transitions, and serve as a patient advocate within the healthcare system.
Key Responsibilities
- Medical necessity review — Apply InterQual, Medical Policy, Care Management guidelines, and clinical judgment to determine appropriateness of requested services.
- Clinical documentation analysis — Review medical history, treatment plans, inpatient/continued stay requests, procedures, and ancillary services.
- Provider collaboration — Communicate with servicing providers to clarify treatment plans and validate medical need.
- Case escalation — Present cases not meeting criteria to the Medical Director for further evaluation.
- Discharge planning — Identify discharge needs early and coordinate with case management or physicians to support safe transitions.
- Quality and compliance — Refer cases to Quality Management or Disease/Case Management when indicated; ensure decisions comply with federal, state, and accreditation regulations.
- Productivity & turnaround — Meet required turnaround times and departmental productivity standards.
- Documentation accuracy — Maintain timely, accurate documentation per Care Management & Coordination policy.
- Trend reporting — Report utilization trends and recommend process improvements.
- Perform additional duties as assigned.
Required Qualifications
- Active PA RN license or Nurse Licensure Compact including PA.
- Must reside in PA, NJ, or DE.
- RN experience in Precertification/Prior Authorization.
- InterQual experience preferred.
- Experience with utilization review for infusion therapy strongly preferred.
