Utilization Review Nurse

IntePros; Philadelphia (Philadelphia County); On-site; USD 60,000 - 80,000; Full time

Job summary

IntePros is seeking a Senior Healthcare Recruiter for the role of Utilization Review Nurse. This position focuses on ensuring high-quality care transitions and requires an active PA RN license and experience in utilization management. The successful candidate will collaborate closely with healthcare providers and manage patient care processes effectively.

Qualifications

• Minimum three years of acute care clinical experience required.
• Prior experience in utilization management or case management needed.
• Strong knowledge of post-acute care settings and managed care principles.

Responsibilities

• Conduct telephonic or onsite utilization management reviews.
• Collaborate with hospital teams and families for discharge planning.
• Identify and report quality of care issues.

Skills

Communication

Problem Solving

Critical Thinking

Organization

Education

Registered Nurse (RN) with active license in PA

Bachelor’s degree in Nursing (BSN)

Tools

EMR systems

Medical necessity review criteria (e.g., InterQual, Milliman)

Job description

This range is provided by IntePros. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$40.00/hr - $45.00/hr

Direct message the job poster from IntePros

Senior Healthcare Recruiter @ IntePros | Technology Staffing

Active PA Licensed RN required. Post Acute and Utilization Management experience required.

General Summary:

The Utilization Review Nurse plays a critical role in ensuring high-quality, cost-effective care transitions for patients requiring post-acute services. This role focuses on utilization management, discharge planning, and coordination of care to the most appropriate setting. The candidate collaborates closely with hospital utilization review teams, attending physicians, and patients 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.

Education & Experience:

• Registered Nurse (RN) with an active license in PA (required).
• Bachelor’s degree in Nursing (BSN) preferred.
• Minimum of three (3) years of acute care clinical experience in a hospital or healthcare setting.
• Prior experience in utilization management, or case management is required.
• 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).

Seniority level

• Seniority level

  Associate

Employment type

• Employment type

  Contract

Job function

• Job function

  Other

• Industries

  Hospitals and Health Care

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