Pennsylvania Licensed Utilization Management RN

Job Summary

To support clinical utilization review and care management activities, the part-time remote Pennsylvania Licensed Utilization Management RN will independently review medical records, assess medical necessity, and collaborate with providers and Medical Directors to ensure appropriate patient care.

Key Responsibilities

• Conduct comprehensive clinical reviews of medical records to determine medical necessity
• Utilize established clinical criteria and resources to evaluate cases and authorize medically necessary services
• Collaborate with Case Management staff and physicians to facilitate timely discharge and identify alternative levels of care

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
• Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe