Utilization Review Nurse

Location: Remote (Must reside in PA, NJ, or DE for future conversion consideration)

Licensure

Required:

Active PA RN license or Nurse Licensure Compact including PA

We’re hiring an experienced Utilization Review Nurse to join our Utilization Management team. This fully remote role is ideal for a clinically strong nurse who thrives in a fast-paced, review-driven environment and brings sound judgment, attention to detail, and a member-focused mindset.

In this role, you’ll evaluate medical records to determine medical necessity, authorize services, collaborate with providers, and help members navigate their care journey. You’ll function as both a clinical reviewer and patient advocate—ensuring care is appropriate, timely, and aligned with established guidelines.

• Review clinical documentation to determine medical necessity for inpatient, outpatient, and ancillary services
• Apply clinical judgment using Inter Qual, medical policies, care management guidelines, and electronic reference tools
• Authorize services that meet criteria and refer non-criteria cases to the Medical Director (This role approves care but does not issue denials)
• Collaborate with providers to obtain additional clinical information and clarify treatment plans
• Support early discharge planning and appropriate care transitions in partnership with case management and physicians
• Advocate for members by helping them navigate benefits and care pathways
• Meet regulatory turnaround times and productivity standards
• Document all utilization decisions accurately and in compliance with Care Management policies
• Identify utilization trends and elevate issues or improvement opportunities as appropriate
• Refer cases to Quality, Case Management, or Disease Management teams when needed

• Active PA RN or LPN license or Compact license including PA —
  required
• BSN preferred

• Minimum of 3 years of acute care clinical experience (hospital or similar setting)
• Outpatient utilization management experience strongly preferred
• Background in discharge planning, medical management, or prior authorization is a plus
• Strong clinical judgment and critical thinking skills
• Clear, professional communication and strong interpersonal abilities
• Excellent organization, time management, and attention to detail
• Ability to prioritize effectively and manage multiple concurrent reviews
• Comfortable working independently in a remote environment
• Adaptable, collaborative, and open to learning new systems and processes
• Proficient in Microsoft Word, Outlook, Excel, SharePoint, Adobe, and other clinical or UM platforms

• Clinically confident reviewing complex medical records
• Experienced in outpatient UM, prior authorization, or medical necessity review
• Highly organized, accurate, and accountable
  
  Member-focused with a strong commitment to quality care
• Thrives in a remote, collaborative, and deadline-driven environment