Utilization Review Nurse — Elevate Care & Payer Approvals

Penn Medicine, University of Pennsylvania Health System; Bala Cynwyd (PA); On-site; USD 80,000 - 110,000; Full time

Job summary

Penn Medicine is seeking an Utilization Review Nurse to conduct timely and accurate utilization reviews to determine medical necessity, admissions, and resource use. This role sits within the centralized Utilization Management department, collaborating with physicians, case management, and revenue cycle to ensure appropriate care levels and compliance.

Qualified candidates are RNs with PA license and 2+ years of acute hospital experience, proficient with InterQual/MCG criteria and denial

Qualifications

• Active RN license in Pennsylvania.
• 2+ years acute hospital care experience.
• Experience using InterQual and MCG criteria for utilization review.
• Experience with utilization management, appeals, or denials management.

Responsibilities

• Conduct medical necessity reviews and patient status determinations using approved clinical criteria and regulatory requirements.
• Perform admission, concurrent, continued stay, and retrospective utilization reviews.
• Manage payer authorization and notification processes to promote timely approvals.
• Identify cases requiring secondary review or physician advisor involvement.
• Collaborate with physicians, case managers, social workers, and interdisciplinary teams to support patient progression and discharge planning.
• Ensure accurate documentation of utilization review activities and payer communications in designated systems.
• Assist with denial prevention activities and CMS/regulatory compliance.
• Monitor compliance with CMS regulations, payer requirements, accreditation standards, and utilization management workflows.

Skills

RN license (PA)

Clinical judgment

Education

BA/BS or higher

Tools

InterQual

MCG

Job description

Penn Medicine is seeking an Utilization Review Nurse to conduct timely and accurate utilization reviews to determine medical necessity, admissions, and resource use. This role sits within the centralized Utilization Management department, collaborating with physicians, case management, and revenue cycle to ensure appropriate care levels and compliance.

Qualified candidates are RNs with PA license and 2+ years of acute hospital experience, proficient with InterQual/MCG criteria and denial