Utilization Review Nurse

IntePros; Pennsylvania; On-site; USD 90,000 - 110,000; Full time

Job summary

An established industry player is seeking a dedicated Utilization and Care Management Coordinator to ensure high-quality care transitions for patients. This critical role involves collaborating with hospital teams and families to optimize healthcare outcomes while managing resources efficiently. The ideal candidate will possess strong communication and problem-solving skills, along with a solid background in utilization management and discharge planning. If you are passionate about improving patient care and thrive in a dynamic healthcare environment, this opportunity is perfect for you.

Qualifications

• Active RN license in PA is required.
• Acute care clinical experience in a healthcare setting.

Responsibilities

• Conduct utilization management reviews for inpatient admissions.
• Collaborate with physicians and hospital staff for effective care transitions.

Skills

Utilization Management

Discharge Planning

Care Coordination

Communication Skills

Problem-Solving

EMR Systems

Education

Registered Nurse (RN)

Bachelor’s Degree in Nursing (BSN)

Tools

InterQual

Milliman

Job description

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The Utilization and Care Management Coordinator plays a critical role in ensuring high-quality, cost-effective care transitions for patients requiring post-acute services. Under the direction of the Care Management and Coordination Supervisor, this role focuses on utilization management, discharge planning, and coordination of care to the most appropriate setting. You'll be collaborating closely with hospital utilization review teams, attending physicians, and members and their families to optimize healthcare outcomes and promote efficient resource utilization.

Key Responsibilities:

• Conduct telephonic or onsite utilization management reviews for inpatient admissions, ensuring medical necessity and appropriate length of stay.
• Utilize medical criteria software to determine the need for inpatient care and facilitate safe, timely transitions to alternative care settings.
• Engage with attending physicians to discuss treatment plans and clarify the medical necessity of inpatient stays.
• Identify hospital admissions that no longer meet inpatient criteria and escalate cases to Medical Directors for further evaluation.
• Collaborate with hospital case management staff, physicians, and families to develop and implement effective discharge plans.
• Facilitate early identification of patients requiring post-acute care services, ensuring a smooth transition to home health, rehabilitation, skilled nursing, or other appropriate settings.
• Refer patients to Case Management or Disease Management programs as needed to support ongoing care needs.
• Identify and report quality of care issues, delays in treatment, or gaps in services to the Quality Management Department or Care Management and Coordination Supervisor.
• Maintain accurate and timely documentation in compliance with state, federal, and accreditation regulations.
• Build and maintain strong relationships with healthcare providers and deliver exceptional customer service.
• Monitor utilization trends and provide recommendations for process improvements.
• Assist in educating providers on managed care best practices and guidelines.
• Perform additional duties as assigned.

Required Qualifications:

Education & Experience:

• Registered Nurse (RN) with an active license in PA (required).
• Bachelor’s degree in Nursing (BSN) preferred.
• Acute care clinical experience in a hospital or healthcare setting.
• Prior experience in discharge planning, utilization management, or case management is highly desirable.
• Strong knowledge of post-acute care settings, managed care principles, and care coordination best practices.
• Excellent communication and interpersonal skills to engage effectively with physicians, hospital staff, patients, and families.
• Strong problem-solving and critical thinking abilities to assess patient needs and recommend appropriate care solutions.
• Ability to work independently while collaborating within a multidisciplinary team.
• Highly organized with strong attention to detail and documentation accuracy.
• Proficiency in EMR systems and medical necessity review criteria (e.g., InterQual, Milliman).

This position is an excellent opportunity for an experienced RN with a passion for care coordination and post-acute care management. If you thrive in a dynamic healthcare environment and are committed to improving patient outcomes through effective care transitions, we encourage you to apply.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Contract

Job function

• Job function

  Health Care Provider and Administrative

• Industries

  Hospitals and Health Care

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