Remote Utilization Management Case Manager

Lehigh Valley Health Network, Inc.; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Lehigh Valley Health Networkis seeking an experienced RN to join the Utilization Management team in a remote role. You will review admissions, determine appropriate patient class, and ensure payer-aligned care decisions using evidence-based criteria.

Responsibilities include educating care teams, documenting authorizations, and collaborating with precert, billing, and finance to optimize reimbursement while maintaining HIPAA compliance.

Qualifications

• RN - Licensed Registered Nurse (PA) Upon Hire.
• 2 years utilization review experience.
• 2 years knowledge of utilization management for third party payers.
• HIPAA confidentiality adherence.
• team-oriented with flexibility to prioritize needs.
• attention to detail and timely work delivery.

Responsibilities

• Review patient admissions to assess appropriateness using approved criteria.
• Educate on appropriate level of care and patient class assignments.
• Provide clinical reviews to support decision-making for payer requirements.
• Develop and improve policies to enhance department efficiency.
• Collaborate with care managers, precert/preservices, and billing teams to ensure accurate reviews.
• Document authorizations and downgrades per policy; participate in Performance Improvement activities.

Education

Specialized Diploma in nursing

Bachelor's Degree in nursing

Job description

Lehigh Valley Health Networkis seeking an experienced RN to join the Utilization Management team in a remote role. You will review admissions, determine appropriate patient class, and ensure payer-aligned care decisions using evidence-based criteria.

Responsibilities include educating care teams, documenting authorizations, and collaborating with precert, billing, and finance to optimize reimbursement while maintaining HIPAA compliance.