Utilization Management RN

About the role

100% remote position; candidate must reside in Pennsylvania, Delaware, or New Jersey. This is a contract role requiring an active Pennsylvania RN license or a Nurse Licensure Compact that includes Pennsylvania. The Care Management Coordinator evaluates members’ clinical conditions through review of medical records to determine medical necessity for services, interacts with providers for additional information, and has authority to authorize medically necessary services while ensuring regulatory compliance and acting as a patient advocate.

Responsibilities

• Applies critical thinking and judgement based on advanced medical knowledge to cases using specified resources and guidelines to make case determinations.
• Utilizes resources such as InterQual, Care Management Policy, Medical Policy, and Electronic Desk References to determine medical appropriateness of proposed plans.
• Uses InterQual and/or Medical Policy criteria to establish need for inpatient, continued stay, length of stay, procedures, and ancillary services.
• Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services.
• Reviews treatment plans/plan of care with provider for requested services/procedures, inpatient admissions or continued stay, clarifying medical information with provider if needed.
• Identifies and refers cases where the plan of care/services are not meeting established criteria to the Medical Director for further evaluation.
• Performs early identification of members to evaluate discharge planning needs.
• Collaborates with case management staff or physicians to determine alternative settings and provide support to facilitate discharge to the most appropriate setting.
• Reports potential utilization issues or trends to designated manager and provides recommendations for improvement.
• Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated, including delays in care.
• Appropriately refers cases to Case and Disease Management.
• Ensures requests are covered within the member’s benefit plan.
• Ensures utilization decisions comply with state, federal, and accreditation regulations.
• Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests.
• Ensures all key functions are documented via Care Management and Coordination Policy.
• Maintains system information integrity through timely, accurate data entry.

Qualifications

• Education: Active PA Licensed RN.
• Experience: Minimum of three (3) years of Medical Surgical clinical experience in a hospital or other health care setting. Prior discharge planning and/or utilization management, InterQual or Millman/Robert’s experience is preferred. Medical management/precertification experience preferred.

Skills

• Exceptional communication, problem solving, and interpersonal skills.
• Action oriented with strong ability to set priorities and obtain results.
• Team player – builds team spirit and interdepartmental rapport using effective problem solving and motivational strategy.
• Open to change, comfortable with new ideas and methods; creates and acts on new opportunities; flexible and adaptable.
• Embrace diversity of workforce and show respect for colleagues internally and externally.
• Excellent organizational planning and prioritizing skills.
• Ability to effectively utilize time management.
• Oriented in current trends of medical practice.
• Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs.
• Ability to learn new systems as technology advances.

Schedule

Part‑time position working every other weekend (2 days per week in a 2‑week cycle). Must be available Monday‑Friday 8:30 am‑4:30 pm for 2‑3 weeks of training at the start of the assignment.