Utilization Review Nurse Job at IntePros, Philadelphia, PA

TkZIZEFKc1ZVb3dPZ1dSVTlRZnpHOGRj
  • IntePros
  • Philadelphia, PA

Job Description

Job Title: Utilization Management RN

Location: Remote must reside within the PA/NJ/DE tri-state area for potential conversion to full-time

License Requirement: Active Pennsylvania RN license or Nurse Licensure Compact (including PA) required

Overview

The Utilization Management RN plays a vital role in evaluating members clinical conditions through detailed medical record review to determine medical necessity for services. Using advanced clinical knowledge and independent analysis, this position applies appropriate medical criteria to support high-quality, cost-effective care decisions.

This is a remote position with the opportunity for future on-site conversion.

Key Responsibilities

  • Apply critical thinking and clinical judgment to determine medical necessity using tools such as InterQual, Care Management Policy, and Medical Policy guidelines.
  • Review and evaluate medical records, treatment plans, and histories to determine the appropriateness of inpatient, outpatient, and ancillary services.
  • Contact providers to clarify or obtain additional clinical information as needed.
  • Independently authorize medically necessary services based on established criteria.
  • Refer cases that do not meet criteria to the Medical Director for further review.
  • Identify members in need of discharge planning and collaborate with case management and physicians to ensure safe transitions of care.
  • Maintain compliance with federal, state, and accreditation regulations and company policies.
  • Document all utilization management activities accurately and timely per departmental procedures.
  • Report potential utilization trends or issues to management with recommendations for improvement.
  • Refer cases appropriately to Case Management, Disease Management, or Quality Management as indicated.
  • Meet or exceed departmental productivity and turnaround time (TAT) goals.

Education/Licensure & Experience

  • Active PA Licensed RN (or Compact License including PA) required
  • BSN preferred
  • Minimum of 3 years of acute care clinical experience (hospital or healthcare setting)
  • Discharge planning and/or utilization management experience preferred
  • Prior medical management or precertification experience a plus

Knowledge, Skills & Abilities

  • Strong clinical assessment, analytical, and problem-solving skills
  • Excellent verbal and written communication abilities
  • Effective prioritization and time management skills
  • Team-oriented with strong collaboration and relationship-building capabilities
  • Adaptable and open to change with a proactive, results-driven mindset
  • Familiarity with current trends in medical practice and utilization management
  • Proficient in Microsoft Word, Outlook, Excel, SharePoint, and Adobe; ability to learn new systems

Job Tags

Full time, Part time,

Similar Jobs

Jplus Ltd.

Online English/ Phonics Teachers Job at Jplus Ltd.

You will be teaching ESL students mostly aged between 4 and 16, students are booked in weekly, usually at the same time, so you'll be able to form a connection with them and have a stable schedule. Classes are 1-on-1 and each class goes on for 40mins. You will receive... 

City of Houston

Electrician Job at City of Houston

Join to apply for the Electrician role at City of Houston6 days ago Be among the first 25 applicantsPosition overviewReporting Location...  ...by the Electrical Safety and Licensing Advisory Board.Experience requirementsNo journey level experience is required.... 

SoTalent

Chief Marketing Officer Job at SoTalent

Position: Chief Marketing and Membership OfficerLocation: Denver, Colorado (Hybrid Schedule)Employment Type: Fulltime, ExemptCompensation: $200,000-$210,000 annually (based on experience)OverviewOur client is seeking an experienced, forwardthinking Chief Marketing... 

Sheet Metal Specialties Inc.

Fabrication Welder Job at Sheet Metal Specialties Inc.

 ...Description Job Description Basic Requirements Include: Knowledge and experience with fabrication and piping system processes Knowledge of proper and effective use of welding equipment and settings for GMAW, FCAM, GTAW, SMAW welders. Mechanically inclined ... 

GoPuff

Gopuff Delivery Driver Partner Job at GoPuff

Job Description Job Description Do more than make ends meet. Deliver with Gopuff and get paid to deliver what your neighbors need from a Gopuff facility near you! With one centralized pickup location and smaller delivery zones, Gopuff makes earning effortless. It's...