Remote Pre-Certification RN – Utilization Review (PA/NJ/DE)

The Judge Group; United States; Remote; USD 51,143 - 72,840; Part time

Job summary

A recruitment agency is seeking a Pre-Certification RN to evaluate clinical conditions and determine medical necessity for services. This remote position requires an active RN license in PA or a Compact license, along with a minimum of 3 years of acute care clinical experience. Responsibilities include authorizing services, ensuring compliance with regulations, and acting as a patient advocate throughout the care process.

Qualifications

• Active RN license in PA or Compact license including PA.
• Minimum 3 years of acute care clinical RN experience in a hospital or healthcare setting.
• Prior discharge planning or utilization management experience preferred.

Responsibilities

• Review medical records to determine medical necessity using InterQual and medical policy criteria.
• Authorize services that meet established criteria; refer non-qualifying cases to the Medical Director.
• Communicate with providers to clarify treatment plans and medical needs.
• Ensure requests align with member benefit plans and regulatory requirements.
• Identify discharge planning needs and collaborate with case management staff.
• Maintain accurate documentation and meet turnaround time and productivity goals.
• Report utilization trends and quality-of-care issues as needed.

Skills

Clinical judgment

Communication skills

Detail-oriented

Education

Active RN license in PA or Compact license including PA

Job description

A recruitment agency is seeking a Pre-Certification RN to evaluate clinical conditions and determine medical necessity for services. This remote position requires an active RN license in PA or a Compact license, along with a minimum of 3 years of acute care clinical experience. Responsibilities include authorizing services, ensuring compliance with regulations, and acting as a patient advocate throughout the care process.