Utilization Review Nurse

Job Title: Utilization Management RNLocation: Remote – must reside within the PA/NJ/DE tri-state area for potential conversion to full-timeLicense Requirement: Active Pennsylvania RN license or Nurse Licensure Compact (including PA) requiredOverviewThe 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 ResponsibilitiesApply 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 & ExperienceActive PA Licensed RN (or Compact License including PA) – requiredBSN preferredMinimum of 3 years of acute care clinical experience (hospital or healthcare setting)Discharge planning and/or utilization management experience preferredPrior medical management or precertification experience a plusKnowledge, Skills & AbilitiesStrong clinical assessment, analytical, and problem-solving skillsExcellent verbal and written communication abilitiesEffective prioritization and time management skillsTeam-oriented with strong collaboration and relationship-building capabilitiesAdaptable and open to change with a proactive, results-driven mindsetFamiliarity with current trends in medical practice and utilization managementProficient in Microsoft Word, Outlook, Excel, SharePoint, and Adobe; ability to learn new systems