Utilization Management RN
Location: Remote (Must Reside in Pennsylvania, New Jersey, or Delaware)
Licensure: Active Pennsylvania RN License or Multistate Compact RN License Required
This role is responsible for performing utilization management reviews to determine the medical necessity and appropriateness of requested healthcare services, ensuring members receive evidence-based care while maintaining compliance with regulatory and accreditation standards.
This position is ideal for a clinically strong RN who thrives in a collaborative environment, enjoys critical thinking, and is passionate about improving patient outcomes through high-quality utilization management.
Key Responsibilities
Conduct medical necessity reviews for healthcare services using InterQual, medical policies, and evidence-based clinical guidelines.
Review medical records, treatment plans, and clinical documentation to determine whether requested services meet established medical necessity criteria.
Collaborate with physicians, providers, and internal clinical teams to obtain additional clinical information and clarify treatment plans when needed.
Present cases that do not meet medical necessity criteria to the Medical Director for final determination.
Identify discharge planning and care coordination needs and collaborate with case management to support appropriate transitions of care.
Ensure authorization decisions comply with federal, state, and accreditation requirements while meeting established turnaround times.
Identify utilization trends, quality concerns, and opportunities for process improvement.
Accurately document clinical reviews and maintain the integrity of utilization and care management systems.
Serve as a clinical resource and advocate for members navigating the healthcare system.
Qualifications
Must reside in Pennsylvania, New Jersey, or Delaware.
Active Pennsylvania Registered Nurse (RN) license or active multistate Compact RN license required.
Previous experience in Utilization Management, Utilization Review, Care Management, Case Management, or Prior Authorization.
Strong understanding of medical necessity review, healthcare regulations, and evidence-based clinical criteria.
Experience utilizing InterQual or similar medical necessity guidelines strongly preferred.
Excellent critical thinking, clinical assessment, communication, and documentation skills.
Ability to independently prioritize a high-volume workload while meeting regulatory turnaround times.
Preferred Experience
Managed care, health plan, or payer experience.
Experience reviewing inpatient, outpatient, specialty, or other healthcare service authorizations.
This is an excellent opportunity for an experienced RN who enjoys combining clinical expertise with analytical decision-making to ensure members receive timely, appropriate, and high-quality care while supporting organizational quality and compliance initiatives.