Utilization Review Nurse

Utilization Management RN | Contract-to-Hire

Location: Remote (Must reside in PA, NJ, or DE)

Licensure Required: Active PA RN license or Nurse Licensure Compact including PA

Department: Care Management & Utilization Review

About the Role

We're hiring an experienced Utilization Review Nurse to join our Utilization Management team. This fully remote role is ideal for a clinically strong UM nurse who thrives in a fast-paced, review-driven environment and brings sound judgment, attention to detail, and a member-focused mindset.

Key Responsibilities

• Review medical records and clinical documentation to determine medical necessity for requested services.
• Apply established clinical guidelines, including InterQual Criteria, medical policy, and care management policies.
• Evaluate requests for therapy services, inpatient admissions, procedures, and ancillary services.
• Communicate with providers to clarify treatment plans and obtain additional clinical information when needed.
• Approve services that meet medical necessity criteria and escalate cases not meeting criteria to Medical Directors for further review.
• Identify discharge planning opportunities and collaborate with care teams to support transitions to appropriate care settings.
• Refer members to case management or disease management programs when appropriate.
• Monitor utilization trends and escalate quality or care delays when identified.
• Ensure all utilization decisions comply with state, federal, and accreditation requirements.
• Maintain accurate documentation and meet required turnaround times and productivity goals.

Qualifications

Required

• Active Pennsylvania RN license or Nurse Licensure Compact license including PA
• Minimum 3 years of Utilization Management/Utilization Review Experience
• 2 years of Insurance/Payer-side UM experience

Preferred

• Prior authorization, precertification, or acute care experience
• Experience applying Interqual or CMS Guidelines