Utilization Review Nurse

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

Position is remote - candidate must reside in PA, DE, or NJ

M-F, day shift + every other weekend

Start: ASAP

Must provide own equipment

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

** Minimum of three (3) years of Medical/Surgical experience.

** Must have Inter Qual exp.

As a Utilization Management RN
, you will assess clinical information, apply evidence‑based criteria, and determine medical necessity for inpatient and outpatient services. You’ll use advanced clinical judgment to review medical records, validate care plans, and authorize services that meet established guidelines. In this role, you’ll collaborate directly with providers, support care coordination, ensure regulatory compliance, and advocate for members navigating the healthcare system.

• Review medical records and apply Inter Qual and medical policy criteria to determine medical necessity for inpatient admissions, continued stays, procedures, and ancillary services.
• Communicate with providers to clarify treatment plans and obtain additional clinical information when needed.
• Refer cases that do not meet criteria to the Medical Director for further evaluation.
• Identify discharge planning needs early and collaborate with case management or physicians to ensure appropriate care settings.
• Report utilization trends and recommend improvements.
• Ensure requests align with member benefit plans and comply with regulatory requirements.
• Meet turnaround times and productivity goals for referral/authorization processing.
• Maintain accurate documentation and data integrity in care management systems.

• Active PA RN license or a Nurse Licensure Compact that includes PA.
• Minimum of three (3) years of Medical/Surgical experience.
• Proficiency with Inter Qual criteria.
• Proficiency in Microsoft applications:
  Word, Outlook, Excel, SharePoint, and Adobe tools.
• Familiarity with current clinical trends and evidence‑based guidelines.