Utilization Management RN-Part Time

Assignment Start Date: September 21, 2026
Assignment End Date: December 26, 2026
Position Type: Part-Time / Remote
Pay rate: $29/hr - $30/hr
Location Requirement: Remote – Candidate must reside in PA, NJ, or DE

Position Overview

We are seeking an experienced Utilization Management Registered Nurse (RN) to support clinical utilization review and care management activities. The RN will independently review medical records, assess medical necessity, apply established clinical criteria, and collaborate with providers and Medical Directors to support appropriate, cost-effective, and compliant patient care.

This position serves as both a clinical resource and patient advocate, helping members navigate the healthcare system while ensuring services are medically appropriate and consistent with benefit plans, regulatory requirements, and accreditation standards.

Schedule & Training

• Part-time schedule: Every other weekend, working 2 days during each 2-week cycle.
• Training: Must be available Monday–Friday, 8:30 AM–4:30 PM for approximately 2–3 weeks of virtual training at the beginning of the assignment.
• Remote position: Candidate must reside in Pennsylvania, New Jersey, or Delaware.
• Candidate must have an active Pennsylvania RN license or a Nurse Licensure Compact (NLC) license that includes Pennsylvania.

Key Responsibilities

• Conduct comprehensive clinical reviews of medical records, including medical history and treatment documentation, to determine medical necessity.
• Apply critical thinking, clinical judgment, and advanced nursing knowledge when evaluating cases.
• Utilize InterQual, Medical Policy, Care Management Policy, and other approved clinical resources to determine medical appropriateness.
• Review requests for inpatient admissions, continued stays, length of stay, procedures, ancillary services, and other healthcare services.
• Contact providers to clarify clinical information, treatment plans, and requested services when additional information is needed.
• Independently authorize services determined to be medically necessary based on established criteria.
• Refer cases that do not meet established criteria to the Medical Director for further review and determination.
• Identify members early in the care process to assess discharge planning needs.
• Collaborate with Case Management staff and physicians to identify appropriate alternative levels of care and facilitate timely discharge.
• Identify and report utilization concerns, trends, delays in care, and opportunities for improvement.
• Refer cases to Quality Management, Care Management and Coordination, Case Management, and Disease Management when appropriate.
• Verify that requested services are covered under the member's benefit plan.
• Ensure utilization management decisions comply with applicable federal and state regulations and accreditation standards.
• Meet or exceed required regulatory turnaround times and departmental productivity standards.
• Maintain accurate and timely documentation in accordance with Care Management and Coordination policies.
• Maintain data integrity through accurate and timely system documentation and data entry.
• Serve as a patient advocate and resource to help members access and navigate the healthcare system.

Required Qualifications

• Active Pennsylvania RN license or Nurse Licensure Compact license that includes Pennsylvania.
• Minimum of 3 years of Medical-Surgical clinical nursing experience.
• Previous Utilization Management and/or discharge planning experience preferred.
• Experience with InterQual or MCG (formerly Milliman) preferred.
• Strong clinical assessment, critical thinking, and decision-making skills.
• Ability to independently review medical records and apply medical necessity criteria.
• Strong provider communication and collaboration skills.
• Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe.
• Ability to learn and adapt to new technology and healthcare information systems.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN) preferred.
• Prior experience in managed care, health plan, utilization review, or care management.
• Experience working with regulatory and accreditation requirements.

Candidate Screening Questions

1. Is the candidate available Monday–Friday, 8:30 AM–4:30 PM for approximately 2–3 weeks of virtual training at the start of the assignment?

   • Yes
   • No

2. Is the candidate available to work every other weekend, 2 days during each 2-week cycle?

   • Yes
   • No

3. Does the candidate reside in the tri-state area of Pennsylvania, New Jersey, or Delaware?

   • Yes
   • No

4. Does the candidate have an active Pennsylvania RN license or a Nurse Licensure Compact license that includes Pennsylvania?

   • Yes
   • No

Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.

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