Utilization Review Nurse

Job Title : Utilization Management RN

Location : Remote must reside within the PA / NJ / DE tri-state area for potential conversion to full-time

License Requirement : Active Pennsylvania RN license or Nurse Licensure Compact (including PA) required

Overview

The Utilization Management RN plays a vital role in evaluating members clinical conditions through detailed medical record review to determine medical necessity for services. Using advanced clinical knowledge and independent analysis, this position applies appropriate medical criteria to support high-quality, cost-effective care decisions.

This is a remote position with the opportunity for future on-site conversion.

Key Responsibilities

• Apply critical thinking and clinical judgment to determine medical necessity using tools such as InterQual, Care Management Policy, and Medical Policy guidelines.
• Review and evaluate medical records, treatment plans, and histories to determine the appropriateness of inpatient, outpatient, and ancillary services.
• Contact providers to clarify or obtain additional clinical information as needed.
• Independently authorize medically necessary services based on established criteria.
• Refer cases that do not meet criteria to the Medical Director for further review.
• Identify members in need of discharge planning and collaborate with case management and physicians to ensure safe transitions of care.
• Maintain compliance with federal, state, and accreditation regulations and company policies.
• Document all utilization management activities accurately and timely per departmental procedures.
• Report potential utilization trends or issues to management with recommendations for improvement.
• Refer cases appropriately to Case Management, Disease Management, or Quality Management as indicated.
• Meet or exceed departmental productivity and turnaround time (TAT) goals.

Education / Licensure & Experience

Knowledge, Skills & Abilities