RN - Utilization Review

Join GHR Healthcare : Seeking a Dynamic Behavioral Health Care Management Coordinator!

Remote - Must reside in PA, NJ, or DE)

Shift : Monday Friday (normal business hours)

Pay Rate : $35.00 -37.00 HR (paid weekly and eligible for health benefits)

Job Summary

The primary role of the Behavioral Health (BH) Care Management Coordinator is to assess a member's behavioral health condition through the comprehensive review of medical records, including medical history and treatment documentation.

This evaluation is conducted to determine the medical necessity of services using advanced knowledge and independent analysis.

When needed, the coordinator will interact directly with providers to gather additional behavioral health information.

Key Responsibilities

• Utilize InterQual, ASAM, and / or Medical Policy criteria to establish the need for inpatient care, continued stay, length of stay, procedures, and ancillary services.
• Contact servicing providers to discuss treatment plans and clarify the medical need for services.
• Review treatment plans with providers for requested services, inpatient admissions, or continued stays, clarifying behavioral health information as needed.
• Identify members early to evaluate discharge planning needs.
• Collaborate with case management staff or physicians to determine alternative settings and facilitate discharge to the most appropriate setting.
• Report potential utilization issues or trends to the designated manager and provide recommendations for improvement.
• Refer cases to the Quality Management Department and / or Care Management and Coordination Manager as needed, including those involving delays in care.
• Refer cases to Case and Disease Management when appropriate.
• Ensure requests are covered within the member's benefit plan.
• Ensure utilization decisions comply with state, federal, and accreditation regulations.

Qualifications

Education

LCSW, LMFT, LPC, or Active PA Licensed RN (BSN Preferred)

Experience

• Minimum of three (3) years of Behavioral Health clinical experience in a hospital or other healthcare setting.
• Prior Behavioral Health utilization management experience is desirable.
• Medical management / precertification experience preferred.
• Weekly direct deposit.
• Health, dental, and vision insurance.
• 401(k) with company matching.
• Paid liability & workers’ comp coverage.
• Flexible scheduling options.
• Referral bonuses.
• Personalized 1 : 1 career support before, during, & and after assignments.

About Us :

With over 30 years of healthcare staffing experience, GHR Healthcare is your trusted partner in finding the perfect contract or permanent role in the healthcare industry.

Our specialized teams have placed thousands of healthcare professionals nationwide. You will have a dedicated recruiter, providing access to new opportunities and guidance every step of the way.

Whatever your career goals, GHR Healthcare is here to support you and find your perfect fit. Get to know us : www.ghrhealthcare.com

We are an equal-opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.