Remote Utilization Management RN – Care Coordinator

IntePros; Philadelphia (Philadelphia County); On-site; USD 85,000 - 110,000; Full time

Job summary

IntePros is seeking a Utilization Management Coordinator / RN to support inpatient utilization management and care coordination. This remote role requires residence in Pennsylvania, New Jersey, or Delaware for potential conversion and involves reviewing medical necessity and determining appropriate levels of care.

You will collaborate with hospital case management teams, Medical Directors, members, and families to promote high-quality, cost-effective care, performing telephonic reviews and

Qualifications

• Active Pennsylvania RN license required.
• Minimum of 3 years of acute-care clinical experience in a hospital or healthcare environment.
• Post-acute care experience required.
• Previous utilization management, utilization review, concurrent review, case management, and/or discharge planning experience preferred.
• Strong understanding of medical necessity, level-of-care determination, discharge planning, and transitions of care.
• Familiarity with InterQual or similar criteria preferred.

Responsibilities

• Perform telephonic utilization management reviews for inpatient hospital admissions.
• Evaluate medical necessity, appropriate level of care, continued stay, and length of stay using established clinical criteria.
• Review treatment plans and collaborate with attending physicians and hospital utilization review teams regarding continued inpatient needs.
• Identify admissions that no longer meet established criteria and elevate cases to Medical Directors for review.
• Present relevant clinical information to Medical Directors regarding the member's condition, treatment plan, discharge needs, and potential home or post-acute care requirements.
• Proactively identify hospitalized members requiring discharge planning support.
• Collaborate with hospital case managers, physicians, members, and families to facilitate safe and timely transitions to the most appropriate setting.
• Evaluate potential alternative levels of care and post-acute services when appropriate.
• Refer members to Case Management and Disease Management programs when additional support is needed.
• Identify potential quality-of-care concerns, including delays in care, and elevate appropriately.
• Maintain timely and accurate documentation of utilization review activities and clinical determinations.
• Ensure utilization decisions comply with applicable state, federal, and accreditation requirements.
• Develop strong working relationships with providers while delivering a high level of customer service.
• Identify utilization trends and potential areas for improvement and communicate findings to leadership.
• Support provider education related to managed care and utilization management processes.

Skills

Active RN license

Acute-care experience

Utilization management experience

Discharge planning

Medical necessity review

Education

BSN or equivalent

Tools

InterQual criteria

Job description

IntePros is seeking a Utilization Management Coordinator / RN to support inpatient utilization management and care coordination. This remote role requires residence in Pennsylvania, New Jersey, or Delaware for potential conversion and involves reviewing medical necessity and determining appropriate levels of care.

You will collaborate with hospital case management teams, Medical Directors, members, and families to promote high-quality, cost-effective care, performing telephonic reviews and