Utilization Review Nurse

The Judge Group; Pennsylvania; Remote; USD 85.000 - 110.000; Vollzeit

Zusammenfassung

A healthcare staffing agency seeks a Utilization Management RN to evaluate clinical conditions through medical record reviews. The position is remote, requiring candidates to reside in PA, DE, or NJ. Key duties involve applying criteria for medical necessity, collaborating with providers, and managing discharge planning. Candidates must have an active PA RN license and a minimum of three years in Medical/Surgical experience, along with proficiency in Microsoft's applications and InterQual criteria.

Qualifikationen

• Must have an active PA RN license or Nurse Licensure Compact including PA.
• Minimum of three years of Medical/Surgical experience.
• Previous acute hospital utilization management and InterQual experience required.
• Previous acute hospital utilization management and InterQual experience required.
• Proficiency in Microsoft Word, Outlook, Excel, SharePoint, and Adobe.
• Remote work but must reside in PA, DE, or NJ.

Aufgaben

• Review medical records and apply criteria for medical necessity.
• Communicate with providers to clarify treatment plans.
• Refer cases to Medical Director for evaluation if criteria are not met.
• Identify discharge planning needs early.
• Report utilization trends and recommend improvements.
• Ensure requests align with member benefit plans.
• Meet turnaround times for processing referrals.
• Maintain accurate documentation.

Kenntnisse

Medical/Surgical experience

Utilization Management experience

InterQual experience

Microsoft Word

Outlook

Excel

SharePoint

Adobe

Ausbildung

BSN

Tools

Microsoft Word

Outlook

Excel

SharePoint

Adobe

Jobbeschreibung

Currently seeking a Utilization Management RN. Please see details and qualifications below:

Position is remote - candidate must reside in the tri-state area (PA, DE, NJ)

M-F, day shift

Start: ASAP

Must provide own equipment

Must have an active PA license or a Nurse Licensure Compact to include PA.

** Minimum of three (3) years of Medical/Surgical experience.

** Previous Acute Hospital Utilization Management and InterQual experience

About the Role

As a Utilization Management RN, you will evaluate members’ clinical conditions through medical record review to determine medical necessity for services. Using advanced clinical knowledge and judgment, you’ll apply InterQual criteria and other guidelines to authorize medically necessary services. You will collaborate with providers, advocate for patients, and ensure compliance with federal, state, and accreditation regulations.

Key Responsibilities

• Review medical records and apply InterQual and medical policy criteria to determine medical necessity for inpatient admissions, continued stays, procedures, and ancillary services.
• Communicate with providers to clarify treatment plans and obtain additional clinical information when needed.
• Refer cases that do not meet criteria to the Medical Director for further evaluation.
• Identify discharge planning needs early and collaborate with case management or physicians to ensure appropriate care settings.
• Report utilization trends and recommend improvements.
• Ensure requests align with member benefit plans and comply with regulatory requirements.
• Meet turnaround times and productivity goals for referral/authorization processing.
• Maintain accurate documentation and data integrity in care management systems.

Qualifications

• Licensure: Active PA RN license or Nurse Licensure Compact including PA.
• Education: BSN preferred.
• Experience:
• Minimum 3 years of Medical/Surgical experience.
• Previous acute hospital utilization management and InterQual experience required.
• Technical Skills: Proficiency in Microsoft Word, Outlook, Excel, SharePoint, and Adobe.
• Location: Remote however must reside in PA, DE, or NJ.