Pennsylvania Licensed Utilization Management RN

Job Summary

A company is looking for a Utilization Management RN to evaluate members' clinical conditions and determine medical necessity for services.

Key Responsibilities

• Review medical records and apply InterQual and medical policy criteria to determine medical necessity for services
• Communicate with providers to clarify treatment plans and obtain additional clinical information
• Identify discharge planning needs and collaborate with case management or physicians for appropriate care settings

Qualifications

• Active PA RN license or Nurse Licensure Compact including PA
• BSN preferred
• Minimum 3 years of Medical/Surgical experience
• Previous acute hospital utilization management and InterQual experience required
• Proficiency in Microsoft Word, Outlook, Excel, SharePoint, and Adobe