Behavioral Health Care Management Coordinator Location:

Remote — must reside in

Pennsylvania, New Jersey, or Delaware Schedule:

Monday-Friday, standard business hours The Behavioral Health Care Management Coordinator reviews behavioral-health and substance-use treatment requests to determine whether requested services meet medical-necessity criteria. This role uses clinical judgment and evidence-based guidelines, including InterQual and ASAM criteria, to support appropriate authorization decisions, provider communication, discharge planning, and member access to behavioral-health services. Key Responsibilities Review medical records, behavioral-health assessments, treatment plans, and provider documentation to evaluate medical necessity for requested services. Apply InterQual Behavioral Health criteria, ASAM criteria, medical policies, care-management policies, and benefit-plan guidelines when completing utilization-management reviews. Assess requests for inpatient admissions, continued stays, length of stay, outpatient services, procedures, and ancillary behavioral-health services. Approve services that meet established medical-necessity criteria within the scope of role authority. Refer cases that do not meet established criteria to the Medical Director for further review and determination. Contact providers to obtain missing clinical information, clarify treatment plans, discuss level-of-care needs, and support complete authorization reviews. Review treatment plans and plans of care to confirm that requested services are clinically appropriate and aligned with member needs. Identify discharge-planning needs early in the review process and collaborate with providers, case managers, and physicians to support transition to the most appropriate level of care. Refer members to case management, disease management, quality management, or other internal programs when additional support is indicated. Serve as a member advocate by helping members understand and navigate behavioral-health services and available care options. Confirm that requested services are covered under the member's benefit plan. Document all reviews, provider contacts, clinical findings, authorization decisions, referrals, and case activity accurately and timely in the care-management system. Maintain productivity, quality, documentation, and turnaround-time standards for authorization and referral requests. Identify utilization trends, delays in care, and opportunities for process improvement, and report findings to leadership. Ensure decisions and documentation comply with applicable federal, state, health-plan, and accreditation requirements. Required Qualifications Active, unrestricted licensure in one of the following: Registered Nurse (RN) with an active Pennsylvania or Compact RN license Licensed Social Worker (LSW) Licensed Clinical Social Worker (LCSW) Licensed Professional Counselor (LPC) Licensed Marriage and Family Therapist (LMFT) Must reside in Pennsylvania, New Jersey, or Delaware. Minimum of three years of behavioral-health clinical experience in a hospital, behavioral-health facility, substance-use treatment setting, outpatient program, or other healthcare environment. Strong knowledge of behavioral-health diagnoses, treatment modalities, levels of care, treatment planning, and discharge-planning practices. Ability to independently review complex clinical records and use critical thinking to make sound utilization-management recommendations. Strong verbal and written communication skills, including the ability to communicate professionally with providers, members, physicians, and internal clinical teams. Proficiency with Microsoft Word, Outlook, Excel, SharePoint, Adobe, and electronic care-management or utilization-review systems. Ability to work independently in a remote environment while meeting productivity, quality, and timeliness expectations. Preferred Qualifications Prior behavioral-health utilization management, utilization review, prior authorization, concurrent review, case management, or care-coordination experience. Experience using InterQual Behavioral Health criteria and/or ASAM criteria. Background in managed care, health-plan operations, Medicaid, Medicare, commercial insurance, or behavioral-health payer programs. Experience reviewing inpatient psychiatric, residential treatment, partial hospitalization, intensive outpatient, outpatient, and substance-use-disorder services. Knowledge of regulatory and accreditation standards affecting behavioral-health utilization management. Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.