Utilization Management RN

Job Description

Care Management Coordinator (Precertification Team – PT / OT / ST & Bariatric Reviews)

Remote – Must Reside in the Tri-State Area (PA, NJ, or DE)

Overview

We are seeking an experienced and detail-oriented Care Management Coordinator to join our Precertification Team, specializing in Physical Therapy, Occupational Therapy, Speech Therapy, and Bariatric procedure reviews. This position is ideal for a nurse with a strong background in orthopedics, general outpatient ambulatory surgery, or surgical units, who thrives in a collaborative and fast-paced remote environment.

Key Responsibilities

• Evaluate member clinical conditions through detailed medical record reviews to determine medical necessity for requested services.
• Apply advanced clinical judgment using InterQual, Care Management Policies, Medical Policies, and other resources to make utilization determinations.
• Contact servicing providers to clarify treatment plans and obtain additional medical information as needed.
• Review treatment plans and proposed procedures for medical appropriateness and ensure they align with benefit coverage and policy criteria.
• Refer cases not meeting established criteria to the Medical Director for further evaluation.
• Identify discharge planning needs early and collaborate with case management or physicians to ensure timely and appropriate transitions of care.
• Monitor and report utilization trends or potential quality issues, recommending process improvements where applicable.
• Maintain compliance with state, federal, and accreditation standards for utilization review and documentation.
• Meet or exceed turnaround and productivity goals for authorization requests.
• Accurately document all activities in accordance with Care Management and Coordination policies.

Qualifications

Education & Licensure

Experience

Skills & Competencies

Why Join Us?

This is a great opportunity to leverage your clinical expertise in a non-bedside, remote role while continuing to make a meaningful impact on patient care. You’ll work alongside a supportive team that values collaboration, innovation, and professional growth.