Utilization Management RN – Infusion Therapy
Location: Fully Remote
Required License: Active Pennsylvania Registered Nurse (RN) License
Position Summary
We are seeking an experienced Registered Nurse to join our Infusion Therapy Care Management team as a Care Management Coordinator. In this fully remote role, you will review clinical documentation and medical records to determine the medical necessity of requested healthcare services while ensuring compliance with evidence-based guidelines, health plan policies, and regulatory requirements.
Key Responsibilities
• Review medical records, treatment plans, and clinical documentation to determine the medical necessity of requested services.
• Apply evidence-based criteria, including InterQual, Medical Policy, and Care Management guidelines to make utilization management decisions.
• Independently approve medically necessary services within established clinical guidelines.
• Collaborate with physicians and healthcare providers to obtain additional clinical information and clarify treatment plans when needed.
• Refer cases that do not meet established medical necessity criteria to the Medical Director for further clinical review.
• Evaluate inpatient admissions, continued stays, procedures, infusion therapies, and ancillary services for medical appropriateness.
• Identify discharge planning opportunities and collaborate with case management teams to facilitate safe and appropriate transitions of care.
• Serve as a clinical resource and patient advocate, helping members navigate the healthcare system and access appropriate services.
• Ensure all utilization management decisions comply with state, federal, and accreditation requirements.
• Maintain accurate and timely documentation within care management systems.
• Identify utilization trends, quality concerns, or delays in care and escalate findings as appropriate.
• Collaborate with Case Management, Disease Management, Quality Management, and other internal partners to coordinate member care.
• Meet departmental productivity, quality, and turnaround time expectations.
Qualifications
• Active Pennsylvania Registered Nurse (RN) License required.
• Associate's or Bachelor's degree in Nursing.
• Experience in Utilization Management, Care Management, Case Management, Prior Authorization, or a related clinical nursing role.
• Experience using InterQual or other evidence-based medical necessity criteria preferred.
• Strong clinical assessment, critical thinking, and decision-making skills.
• Excellent communication and collaboration skills.
• Strong organizational skills with the ability to manage multiple priorities in a fast-paced environment.
• Proficiency with electronic medical records and Microsoft Office applications.
Preferred Qualifications
• Experience supporting Infusion Therapy patients.
• Managed care or health insurance experience.
• Knowledge of CMS, NCQA, URAC, and other healthcare regulatory standards.
• Experience with discharge planning and care coordination.