Remote Utilization Review Nurse | RN, Medical Necessity

Penn Medicine, University of Pennsylvania Health System; Bala Cynwyd (PA); On-site; USD 80,000 - 110,000; Full time

Job summary

Penn Medicine is hiring an Utilization Review Nurse within the Corporate Utilization Management unit. The role conducts medical necessity reviews, manages payer authorizations, and collaborates with physicians and care teams to ensure appropriate patient care and efficient resource use.

The position requires RN licensure, a Bachelor's degree, and 2+ years in acute hospital care, with InterQual/MCG experience preferred.

Qualifications

• Registered Nurse with active license.
• Bachelor's degree required.
• 2+ years of acute hospital care experience.
• Experience with InterQual and MCG preferred.

Responsibilities

• Conduct medical necessity reviews and patient status determinations using approved clinical criteria, regulatory requirements, and organizational policies.
• Perform admission, concurrent, continued stay, and retrospective utilization reviews for appropriate level of care.
• Manage payer authorization and notification processes to promote timely approvals and reduce financial risk.
• Identify and escalate cases requiring secondary review, physician advisor involvement, or additional clinical documentation.
• Collaborate with physicians, case managers, social workers, and interdisciplinary teams to support patient progression and discharge planning.
• Ensure accurate and timely documentation of utilization review activities and payer communications.
• Monitor and maintain compliance with CMS regulations, payer requirements, accreditation standards, and workflows.
• Perform duties as assigned to support the utilization management unit.

Skills

Utilization review

Clinical documentation

Regulatory compliance

Collaborative care

Education

Bachelor's degree

RN license

CCM/ACM certification preferred

Job description

Penn Medicine is hiring an Utilization Review Nurse within the Corporate Utilization Management unit. The role conducts medical necessity reviews, manages payer authorizations, and collaborates with physicians and care teams to ensure appropriate patient care and efficient resource use.

The position requires RN licensure, a Bachelor's degree, and 2+ years in acute hospital care, with InterQual/MCG experience preferred.