Utilization Management RN

Utilization Management RN

We’re actively seeking qualified candidates for a Utilization Management Coordinator / RN opportunity supporting inpatient utilization management and care coordination. This position is remote; however, candidates must reside in Pennsylvania, New Jersey, or Delaware to be eligible for potential conversion.

Position Overview

The Utilization Management Coordinator / RN performs utilization management reviews for inpatient hospital admissions and works closely with providers, hospital case management teams, Medical Directors, members, and families to promote high-quality, cost-effective care.

This individual will evaluate medical necessity and continued stay, identify discharge planning needs, and help facilitate transitions to the most appropriate level and setting of care.

Key Requirements

• Active Pennsylvania RN license required
• Post-acute care experience required
• Minimum of 3 years of acute-care clinical experience in a hospital or healthcare setting
• Utilization management and/or discharge planning experience strongly preferred
• Experience reviewing medical necessity, level of care, continued stay, and length of stay
• Experience working with clinical criteria such as InterQual or similar tools preferred

Responsibilities

• Perform telephonic utilization management reviews for inpatient hospital admissions.
• Evaluate medical necessity, appropriate level of care, continued stay, and length of stay using established clinical criteria.
• Review treatment plans and collaborate with attending physicians and hospital utilization review teams regarding continued inpatient needs.
• Identify admissions that no longer meet established criteria and escalate cases to Medical Directors for review.
• Present relevant clinical information to Medical Directors regarding the member’s condition, treatment plan, discharge needs, and potential home or post-acute care requirements.
• Proactively identify hospitalized members requiring discharge planning support.
• Collaborate with hospital case managers, physicians, members, and families to facilitate safe and timely transitions to the most appropriate setting.
• Evaluate potential alternative levels of care and post-acute services when appropriate.
• Refer members to Case Management and Disease Management programs when additional support is needed.
• Identify potential quality-of-care concerns, including delays in care, and escalate appropriately.
• Maintain timely and accurate documentation of utilization review activities and clinical determinations.
• Ensure utilization decisions comply with applicable state, federal, and accreditation requirements.
• Develop strong working relationships with providers while delivering a high level of customer service.
• Identify utilization trends and potential areas for improvement and communicate findings to leadership.
• Support provider education related to managed care and utilization management processes.

Qualifications

• Active Pennsylvania Registered Nurse (RN) license required.
• Minimum of 3 years of acute-care clinical experience in a hospital or healthcare environment.
• Post-acute care experience required.
• Previous utilization management, utilization review, concurrent review, case management, and/or discharge planning experience preferred.
• Strong understanding of medical necessity, level-of-care determination, discharge planning, and transitions of care.
• Excellent clinical judgment and problem-solving skills.
• Strong written and verbal communication skills with the ability to effectively collaborate with physicians, providers, and multidisciplinary teams.
• Highly organized with the ability to manage multiple cases and competing priorities.
• Strong team-oriented approach and commitment to quality patient care.