Utilization Management RN

Utilization Management RN (Contract)

100% Remote | Tri-State Area (PA, DE, NJ) | M-F Day Shift

Job SummaryRN Utilization Management Nurse reviews medical records to determine medical necessity using InterQual criteria. Independently authorizes medically necessary services (inpatient, procedures, ancillary) and refers non-approved cases to Medical Director. Cannot deny care. Ensures federal/state regulatory compliance.

Key Responsibilities

• Applies InterQual/Medical Policy for inpatient stays, LOS, procedures authorization

• Contacts providers to clarify treatment plans/medical necessity

• Identifies discharge planning needs; supports transitions to appropriate settings

• Documents per UM policy; meets TAT/productivity standards

• Reports utilization trends/issues to management

• Refers quality/utilization cases as indicated

Required Qualifications

• Active PA license or NLC including PA

• 3+ years Med/Surg clinical experience

• Acute hospital Utilization Management + InterQual required

• Must reside in PA, DE, or NJ

• Proficient: MS Word, Excel, Outlook, SharePoint, Adobe

• RN provides own equipment

Duration: 3 months w/ extension & conversion potential

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