Utilization Review Nurse

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

Position is remote - candidate must reside in the tri-state area (PA, DE, NJ)

M-F, day shift

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.

** Previous Acute Hospital Utilization Management and Inter Qual experience

As a Utilization Management RN
, you will evaluate members’ clinical conditions through medical record review to determine medical necessity for services. Using advanced clinical knowledge and judgment, you’ll apply Inter Qual criteria and other guidelines to authorize medically necessary services. You will collaborate with providers, advocate for patients, and ensure compliance with federal, state, and accreditation regulations.

• 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.

• Licensure: Active PA RN license or Nurse Licensure Compact including PA.
• Education: BSN preferred.
• Experience:
• Minimum 3 years of Medical/Surgical experience.
• Previous acute hospital utilization management and Inter Qual experience required.
• Technical
  
  Skills:
  
  Proficiency in Microsoft Word, Outlook, Excel, SharePoint, and Adobe.
• Location: Remote however must reside in PA, DE, or NJ.