Care Manager

Currently seeking a Care Management RN . Please see details and qualifications below :

Position is remote - candidate must reside in the tri-state area (PA, DE, NJ)

M-F, day shift

Must have an active PA license or a Nurse Licensure Compact to include PA.

• Minimum of three (3) years of Acute Care clinical experience in a hospital or other health care setting.

Job Summary : The Care Management RN primary responsibility is to evaluate a member’s clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for patient’s services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, they will directly interact with providers to obtain additional clinical information. The Care Management RN has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For those cases that do not meet established criteria, they will provide relevant information regarding members medical condition to the Medical Director for their further review and evaluation. The Care Management RN has the authority to approve but cannot deny the care for patients. They are also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, they act as a patient advocate and a resource for members when accessing and navigating the health care system.

Responsibilities :