Pennsylvania Licensed Utilization Manager RN

Job Summary

To support healthcare operations, the contract Utilization Manager RN will evaluate members' clinical conditions remotely, ensuring medical necessity and compliance with policies while collaborating with providers and managing care transitions.

Key Responsibilities

• Apply medical necessity criteria to determine appropriate levels of care using established guidelines
• Conduct clinical reviews for various services and communicate with providers to clarify treatment plans
• Present cases not meeting criteria to the Medical Director and collaborate on discharge planning needs

Required Qualifications

• Active PA RN license or Nurse Licensure Compact (NLC) including PA
• Must reside in PA, NJ, or DE
• Minimum 3 years of Medical/Surgical RN experience
• Experience in Utilization Management and Case Management, including PT/OT/ST and bariatric cases
• BSN preferred