Utilization Review Nurse

Active PA Licensed RN required. Post Acute and Utilization Management experience required.

General Summary:

The Utilization Review Nurse plays a critical role in ensuring high-quality, cost-effective care transitions for patients requiring post-acute services. This role focuses on utilization management, discharge planning, and coordination of care to the most appropriate setting. The candidate collaborates closely with hospital utilization review teams, attending physicians, and patients and their families to optimize healthcare outcomes and promote efficient resource utilization.

Key Responsibilities:

• Conduct telephonic or onsite utilization management reviews for inpatient admissions, ensuring medical necessity and appropriate length of stay.
• Utilize medical criteria software to determine the need for inpatient care and facilitate safe, timely transitions to alternative care settings.
• Engage with attending physicians to discuss treatment plans and clarify the medical necessity of inpatient stays.
• Identify hospital admissions that no longer meet inpatient criteria and escalate cases to Medical Directors for further evaluation.
• Collaborate with hospital case management staff, physicians, and families to develop and implement effective discharge plans.
• Facilitate early identification of patients requiring post-acute care services, ensuring a smooth transition to home health, rehabilitation, skilled nursing, or other appropriate settings.
• Refer patients to Case Management or Disease Management programs as needed to support ongoing care needs.
• Identify and report quality of care issues, delays in treatment, or gaps in services to the Quality Management Department or Care Management and Coordination Supervisor.
• Maintain accurate and timely documentation in compliance with state, federal, and accreditation regulations.
• Build and maintain strong relationships with healthcare providers and deliver exceptional customer service.
• Monitor utilization trends and provide recommendations for process improvements.
• Assist in educating providers on managed care best practices and guidelines.

Education & Experience:

• Registered Nurse (RN) with an active license in PA (required).
• Bachelor’s degree in Nursing (BSN) preferred.
• Minimum of three (3) years of acute care clinical experience in a hospital or healthcare setting.
• Prior experience in utilization management, or case management is required.

Skills & Competencies:

• Strong knowledge of post-acute care settings, managed care principles, and care coordination best practices.
• Excellent communication and interpersonal skills to engage effectively with physicians, hospital staff, patients, and families.
• Strong problem-solving and critical thinking abilities to assess patient needs and recommend appropriate care solutions.
• Ability to work independently while collaborating within a multidisciplinary team.
• Highly organized with strong attention to detail and documentation accuracy.
• Proficiency in EMR systems and medical necessity review criteria (e.g., InterQual, Milliman).