Utilization Management/Discharge Planner

Job Title

Utilization Review Nurse (RN) – Medical Management (Remote)

Job Summary

The Utilization Review Nurse (RN) is responsible for evaluating members’ clinical conditions through comprehensive review of medical records, including medical history and treatment plans, to determine medical necessity for healthcare services. This role requires advanced clinical knowledge, critical thinking, and independent decision-making using established medical necessity criteria such as InterQual and internal medical policies.

This is a fully remote position requiring a high level of autonomy, accountability, and the ability to manage a high-volume caseload in a virtual environment. The RN independently authorizes medically necessary services and collaborates with providers telephonically or electronically to obtain additional clinical information when needed. Cases that do not meet established criteria are escalated to the Medical Director for further review. This role does not have denial authority but plays a key role in supporting appropriate care decisions.

The Utilization Review Nurse also ensures compliance with federal, state, and accreditation standards while serving as a patient advocate, helping members navigate the healthcare system and access appropriate care.

Key Responsibilities

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Perform medical necessity reviews using clinical judgment and evidence-based criteria (e.g., InterQual, Medical Policy, Care Management guidelines).
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Evaluate requests for inpatient admissions, continued stays, procedures, and ancillary services to determine appropriateness and level of care.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Independently approve services that meet established medical necessity criteria.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Collaborate with physicians and providers via phone and electronic communication to clarify treatment plans and obtain additional clinical documentation.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Escalate cases that do not meet criteria to the Medical Director with a comprehensive clinical summary.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Identify discharge planning needs early and coordinate with case management to support safe and timely transitions of care.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Recommend alternative levels of care when appropriate to ensure cost-effective and clinically appropriate treatment.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Monitor and report utilization trends, issues, or variances to leadership with recommendations for improvement.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Refer cases to Quality Management, Care Management, or Disease Management programs as appropriate.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Ensure services are aligned with members’ benefit plans and coverage guidelines.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Maintain compliance with regulatory requirements including state, federal, and accreditation standards (e.g., NCQA, URAC).
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Meet or exceed turnaround times and productivity benchmarks for authorization and review processes in a remote production environment.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Accurately document all review activities in accordance with care management policies using electronic systems.
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Maintain data integrity through timely and accurate entry into utilization management platforms.
  
  

Qualifications

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Active, unrestricted Registered Nurse (RN) license in Pennsylvania (required)
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Bachelor of Science in Nursing (BSN) preferred
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Minimum of 3 years of clinical experience in a hospital setting, preferably in Medical-Surgical nursing
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Prior experience in utilization management, discharge planning, case management, or precertification preferred
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Experience with InterQual and/or Milliman/MCG guidelines strongly preferred
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Previous remote or telephonic utilization review experience preferred
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Strong computer proficiency and ability to navigate multiple systems simultaneously
  
  

Preferred Skills

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Experience working in a fully remote or work-from-home healthcare role
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Familiarity with regulatory standards (NCQA, CMS, URAC)
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Strong self-management, organization, and time management skills
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Ability to work independently with minimal supervision in a production-driven environment
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Strong written and verbal communication skills for virtual collaboration
  
  

Remote Work Requirements

• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Dedicated, HIPAA-compliant home workspace
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Reliable high-speed internet connection
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Ability to work standard business hours aligned to organizational needs (may include time zone alignment)
• p]:pt-0 [&>p]:mb-2 [&>p]:my-0" style=""> Comfortable working on-screen for extended periods and managing a high-volume caseload
  
  

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