Utilization Review Nurse

The Judge Group; Pennsylvania; Remote; USD 70,000 - 90,000; Full time

Job summary

A healthcare staffing agency is seeking a Utilization Management RN to work remotely from PA, DE, or NJ. The role involves assessing clinical information, determining medical necessity for services, and collaborating with providers. Candidates should have at least three years of Medical/Surgical experience and proficiency with InterQual criteria. This position offers a day shift workload with flexible weekends and requires an active PA RN license.

Qualifications

• Minimum of three years of Medical/Surgical experience.
• Proficiency with InterQual criteria.
• Proficiency in Microsoft applications.

Responsibilities

• Review medical records and apply InterQual and medical policy criteria.
• Communicate with providers to clarify treatment plans.
• Identify discharge planning needs early.

Skills

Medical/Surgical experience

InterQual proficiency

Microsoft Word

Microsoft Outlook

Microsoft Excel

SharePoint

Adobe tools

Education

Active PA RN license

Job description

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

Position is remote - candidate must reside in PA, DE, or NJ

M-F, day shift + every other weekend

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.

**Must have InterQual exp.

About the Role

As a Utilization Management RN, you will assess clinical information, apply evidence‑based criteria, and determine medical necessity for inpatient and outpatient services. You’ll use advanced clinical judgment to review medical records, validate care plans, and authorize services that meet established guidelines. In this role, you’ll collaborate directly with providers, support care coordination, ensure regulatory compliance, and advocate for members navigating the healthcare system.

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

• Active PA RN license or a Nurse Licensure Compact that includes PA.
• Minimum of three (3) years of Medical/Surgical experience.
• Proficiency with InterQual criteria.
• Proficiency in Microsoft applications: Word, Outlook, Excel, SharePoint, and Adobe tools.
• Familiarity with current clinical trends and evidence‑based guidelines.