Utilization Management RN
Remote
Position Overview
The Care Management Coordinator evaluates members' clinical conditions through comprehensive medical record review to determine medical necessity for services using advanced clinical knowledge and evidence-based criteria. This remote role requires residence in the tri-state area (PA, DE, NJ) and an active PA RN license or Nurse Licensure Compact including PA.
Key Responsibilities
Apply critical thinking and advanced medical knowledge to make case determinations using InterQual, Care Management Policy, Medical Policy, and electronic desk references
Utilize InterQual and/or Medical Policy criteria to establish medical necessity for inpatient admissions, continued stays, length of stay, procedures, and ancillary services
Contact servicing providers regarding treatment plans and plans of care; clarify medical necessity for requested services and procedures
Review treatment plans with providers for requested services, inpatient admissions, or continued stays; obtain additional clinical information as needed
Identify and refer cases not meeting established criteria to the Medical Director for further evaluation and determination
Perform early identification of members to evaluate discharge planning needs and facilitate transitions to appropriate care settings
Collaborate with case management staff and physicians to determine alternative care settings and support discharge planning
Report potential utilization issues or trends to management with recommendations for improvement
Refer cases to Quality Management Department and/or Care Management and Coordination Manager when indicated, including delays in care
Appropriately refer cases to Case and Disease Management programs
Ensure requests are covered within the member's benefit plan
Ensure utilization decisions comply with state, federal, and accreditation regulations (NCQA, CMS, Medicaid/Medicare)
Meet or exceed regulatory turnaround time and departmental productivity goals when processing referral/authorization requests
Document all key functions per Care Management and Coordination Policy
Maintain system information integrity through timely, accurate data entry
Act as patient advocate and resource for members navigating the healthcare system
Perform additional duties as assigned
Apply critical thinking and advanced medical knowledge to make case determinations using InterQual, Care Management Policy, Medical Policy, and electronic desk references
Utilize InterQual and/or Medical Policy criteria to establish medical necessity for inpatient admissions, continued stays, length of stay, procedures, and ancillary services
Contact servicing providers regarding treatment plans and plans of care; clarify medical necessity for requested services and procedures
Review treatment plans with providers for requested services, inpatient admissions, or continued stays; obtain additional clinical information as needed
Identify and refer cases not meeting established criteria to the Medical Director for further evaluation and determination
Perform early identification of members to evaluate discharge planning needs and facilitate transitions to appropriate care settings
Collaborate with case management staff and physicians to determine alternative care settings and support discharge planning
Report potential utilization issues or trends to management with recommendations for improvement
Refer cases to Quality Management Department and/or Care Management and Coordination Manager when indicated, including delays in care
Appropriately refer cases to Case and Disease Management programs
Ensure requests are covered within the member's benefit plan
Ensure utilization decisions comply with state, federal, and accreditation regulations (NCQA, CMS, Medicaid/Medicare)
Meet or exceed regulatory turnaround time and departmental productivity goals when processing referral/authorization requests
Document all key functions per Care Management and Coordination Policy
Maintain system information integrity through timely, accurate data entry
Act as patient advocate and resource for members navigating the healthcare system
Perform additional duties as assigned
Required Qualifications
Minimum of three (3) years of Medical/Surgical nursing experience
Previous Hospital Utilization Management experience required
InterQual experience required
Must have an active PA RN license or Nurse Licensure Compact to include PA
Candidate must reside in the tri-state area (PA, DE, NJ)
Remote position
Minimum of three (3) years of Medical/Surgical nursing experience
Previous Hospital Utilization Management experience required
InterQual experience required
Must have an active PA RN license or Nurse Licensure Compact to include PA
Candidate must reside in the tri-state area (PA, DE, NJ)
Remote position
Preferred Qualifications
Bachelor of Science in Nursing (BSN)
Experience with MCG criteria a plus
Knowledge of federal, state, and accreditation regulations (NCQA, CMS, Medicaid/Medicare)
Bachelor of Science in Nursing (BSN)
Experience with MCG criteria a plus
Knowledge of federal, state, and accreditation regulations (NCQA, CMS, Medicaid/Medicare)
Work Environment
Fully remote position
Candidate must reside in Pennsylvania, Delaware, or New Jersey
May require occasional provider phone contact for clinical clarification
Fully remote position
Candidate must reside in Pennsylvania, Delaware, or New Jersey
May require occasional provider phone contact for clinical clarification
Authority & Scope
Has authority to independently authorize services determined medically necessary based on personal review
Can approve care but cannot deny care; cases not meeting criteria are referred to Medical Director
Has authority to commit the company financially by authorizing medically necessary services
Has authority to independently authorize services determined medically necessary based on personal review
Can approve care but cannot deny care; cases not meeting criteria are referred to Medical Director
Has authority to commit the company financially by authorizing medically necessary services