Utilization Review Nurse — Corporate UM

Penn Medicine; Pennsylvania; On-site; USD 75,000 - 95,000; Full time

Job summary

Penn Medicine seeks a dedicated Utilization Review Nurse to ensure appropriate patient status and medical necessity reviews within our centralized Utilization Management department. You will collaborate with physicians, case management and interdisciplinary teams to support discharge planning and compliant authorization processes.

The role requires PA RN licensure, CCM or ACM certification, a BA/BS, and 2+ years of acute hospital experience, with familiarity in Interqual and MCG guidelines.

Qualifications

• RN PA licensure required in Pennsylvania.
• CCM or ACM certification required.
• Bachelor of Arts or Science degree required.
• 2+ years acute hospital care experience preferred.

Responsibilities

• Conduct medical necessity reviews and patient status determinations using approved clinical criteria, regulatory requirements, and organizational policies.
• Perform admission, concurrent, continued stay, and retrospective utilization reviews to ensure appropriate level of care and resource utilization.
• Manage payer authorization and notification processes to promote timely approvals and reduce financial risk.
• Identify and escalation cases that require secondary review, physician advisor involvement, or additional clinical documentation.
• Collaborate with physicians, case managers, social workers, and interdisciplinary teams to support appropriate patient progression, discharge planning, and utilization management goals.
• Ensure accurate and timely documentation of utilization review activities, authorization determinations, and payer communications within designated systems.
• Assist with denial prevention activities through proactive identification of medical necessity, documentation, authorization, and patient status concerns.
• Monitor and maintain compliance with CMS regulations, payer requirements, accreditation standards, organizational policies, and utilization management workflows

Skills

Registered Nurse - PA

CCM/ACM certification

Education

Bachelor of Arts or Science

Job description

Penn Medicine seeks a dedicated Utilization Review Nurse to ensure appropriate patient status and medical necessity reviews within our centralized Utilization Management department. You will collaborate with physicians, case management and interdisciplinary teams to support discharge planning and compliant authorization processes.

The role requires PA RN licensure, CCM or ACM certification, a BA/BS, and 2+ years of acute hospital experience, with familiarity in Interqual and MCG guidelines.