Utilization Review Nurse

IntePros; Pennsylvania; On-site; USD 75,000 - 90,000; Full time

Job summary

A healthcare staffing firm is seeking a skilled Utilization Review RN to join their team. This fully remote position requires a valid PA RN license and prior experience in insurance utilization review. Responsibilities include conducting clinical reviews, applying evidence-based criteria for patient treatment, and collaborating with healthcare providers. Strong clinical judgment and familiarity with review tools are essential for this role. The ideal candidate will have 2-5+ years of experience in the field.

Qualifications

• Must have an active and unrestricted PA RN license or Compact license.
• 2-5+ years of experience in insurance utilization review required.
• Proficient in using clinical review tools and electronic health records.

Responsibilities

• Conduct clinical reviews to determine medical necessity and appropriateness of care.
• Apply evidence-based criteria to assess patient treatment plans and services.
• Collaborate with healthcare providers and insurance partners.

Skills

Clinical judgment

Knowledge of hospital workflows

Proficiency in clinical review tools

Familiarity with InterQual criteria

Familiarity with Milliman criteria

Education

Active and unrestricted PA RN license

2-5+ years of experience in insurance utilization review

Tools

Electronic health records

Job description

Location:

Fully remote (PA RN License or Compact including PA Required), Must Reside in PA, NJ, or DE

Employment type:

Contract to full-time hire

Position Overview:

We are seeking a skilled and detail-oriented Utilization Review RN with a valid PA license (or Compact)to join our team. This position is ideal for an RN with prior work in insurance utilization review.

Key Responsibilities:

• Conduct clinical reviews to determine medical necessity and appropriateness of care
• Apply evidence-based criteria to assess patient treatment plans and services
• Collaborate with healthcare providers and insurance partners to ensure efficient, quality patient care
• Document review findings accurately and in a timely manner
• Maintain compliance with internal and external regulatory standards

Required Qualifications:

• Active and unrestricted PA RN license (or Compact license including PA)
• 2-5+ years ofprior experience in insurance utilization review
• Strong clinical judgment and knowledge of hospital workflows
• Proficient in using clinical review tools and electronic health records
• Familiarity with InterQual or Milliman criteria.