Remote utilization management RN role focused on reviewing inpatient and post-acute cases to determine medical necessity, continued stay, and appropriate length of stay. The clinician evaluates medical records, applies InterQual criteria, and helps direct members to the most appropriate care setting. The role also includes physician communication, case escalation to medical directors, and early discharge planning support.
Key Responsibilities
- Perform utilization management reviews for inpatient admissions, either onsite or telephonically.
- Review medical records to assess medical necessity, continued stay, and length of stay using medical software criteria.
- Contact attending physicians to clarify treatment plans and the need for inpatient or continued inpatient care.
- Identify admissions that no longer meet criteria and refer cases to plan medical directors for review.
- Present nonconforming cases to medical directors with relevant clinical information and anticipated home care needs.
- Evaluate hospitalized members early to support discharge planning needs.
- Direct care to the most appropriate setting while maintaining quality standards.
Required
- Active Pennsylvania RN license or Nurse Licensure Compact license that includes Pennsylvania.
- Minimum of 3 years of acute care clinical RN experience in a hospital.
- Utilization management experience in the post-acute setting.
- Experience reviewing cases for medical necessity.
- Understanding of InterQual criteria.
Benefits & Perks
- Remote work arrangement.
- Medical, dental, and vision insurance for qualified candidates.
- Day shift schedule, Monday through Friday.
- Start available ASAP.
- Candidate must provide own equipment.