Pennsylvania Licensed Utilization Review Nurse

Job Summary

To support a growing centralized Utilization Management department, the full-time Pennsylvania Licensed Utilization Review Nurse will conduct medical necessity reviews, manage payer authorization processes, and collaborate with interdisciplinary teams to ensure appropriate patient care, all in a remote work environment.

Key responsibilities

• Conduct medical necessity reviews and patient status determinations using clinical criteria and regulatory requirements
• Perform admission, concurrent, and retrospective utilization reviews to ensure appropriate level of care
• Manage payer authorization processes to promote timely approvals and reduce financial risk

Required qualifications

• Registered Nurse license is required
• Bachelor's degree is required
• 2+ years of Acute Hospital Care experience is required
• Experience with Interqual and MCG is preferred
• Previous Utilization Management, Appeals, or Denials Management experience is preferred