Strategic Utilization Review Nurse – Care & Compliance

Penn Medicine; Bala Cynwyd (PA); On-site; USD 85,000 - 110,000; Full time

Job summary

Penn Medicine is seeking an Utilization Review Nurse to support timely and accurate utilization review activities, ensuring medical necessity and appropriate levels of care in a major academic medical center setting.

The role collaborates with physicians, case management, revenue cycle, and care teams to facilitate approvals, documentation, and compliant utilization management across the organization.

Qualifications

• Bachelor of Arts or Science required.
• Experience with InterQual and MCG guidelines.
• 2+ years acute hospital care experience.
• Utilization management, appeals, or denials management experience.

Responsibilities

• Conduct medical necessity reviews and patient status determinations using approved criteria and policies.
• Perform admission, concurrent, continued stay, and retrospective utilization reviews.
• Manage payer authorization and notification processes to promote timely approvals.
• Identify and escalate cases needing secondary review or physician advisor involvement.
• Collaborate with physicians, case managers, social workers, and teams for patient progression and discharge planning.
• Ensure accurate documentation of utilization activities and payer communications.
• Assist with denial prevention activities through documentation and authorization checks.
• Monitor CMS regulations, payer requirements, and accreditation standards.

Skills

Utilization review

Nursing

Regulatory compliance

Education

RN PA license

ACM/CCM certification

Tools

InterQual/MCG guidelines

Job description

Penn Medicine is seeking an Utilization Review Nurse to support timely and accurate utilization review activities, ensuring medical necessity and appropriate levels of care in a major academic medical center setting.

The role collaborates with physicians, case management, revenue cycle, and care teams to facilitate approvals, documentation, and compliant utilization management across the organization.