Utilization Review Nurse

Active PA Licensed RN or LPN required.Job SummaryWe are seeking a detail-oriented and knowledgeable Care Management Coordinator to join our Utilization Management Clinical Precertification Team. In this role, you will assess members' clinical conditions by reviewing medical records and applying medical necessity criteria to ensure appropriate patient care. Your expertise will enable you to independently authorize medically necessary services and advocate for patients navigating the healthcare system. Additionally, you will collaborate with providers to obtain clinical information and escalate complex cases to the Medical Director when necessary. This position also requires ensuring regulatory compliance with federal, state, and accreditation standards.Key ResponsibilitiesApply critical thinking and advanced medical knowledge to evaluate cases, utilizing resources such as InterQual, Care Management Policy, and Medical Policy to determine the appropriateness of care.Assess inpatient admissions, continued stay, procedures, and ancillary services using InterQual criteria and established guidelines.Communicate with servicing providers regarding treatment plans, clarifying medical necessity for requested services and procedures.Refer cases that do not meet established criteria to the Medical Director for further evaluation.Identify patients requiring discharge planning and collaborate with case management staff to facilitate appropriate transitions of care.Monitor utilization trends and report potential concerns, offering recommendations for improvement.Refer cases to Quality Management, Case, and Disease Management teams as necessary.Ensure utilization decisions align with state, federal, and accreditation regulations and meet required turnaround times.Maintain accurate and timely documentation of all case determinations and activities.QualificationsEducation:Active PA Licensed RN or LPN required.BSN preferred.Experience:Minimum of three (3) years of acute care clinical experience in a hospital or healthcare setting.Prior discharge planning and/or utilization management experience is preferred.Experience in medical management and precertification is a plus.Skills & Competencies:Strong analytical, problem-solving, and decision-making skills.Excellent communication and interpersonal abilities.Team-oriented with a collaborative mindset.Ability to adapt to change and embrace new processes and technologies.Knowledge of current medical practices and healthcare trends.Proficiency in Microsoft Office Suite (Word, Outlook, Excel, SharePoint, Adobe) and the ability to learn new systems.

Created: 2025-02-18