RN - Utilization Management Quality ReviewLocation: Remote; candidates must reside in the Tri-State area
Licensure: Active Pennsylvania RN license required
Position SummaryThe RN is responsible for supporting quality and compliance within Utilization Management operations. This role reviews clinical documentation, medical necessity determinations, and member communications to ensure accuracy and compliance with applicable regulatory and accreditation requirements, including NCQA, CMS, and state-specific standards. The RN will conduct quality reviews of Utilization Management cases to confirm that clinical staff are appropriately applying InterQual criteria, medical policies, and departmental guidelines, making appropriate referrals to Medical Directors, and documenting cases accurately for member letter generation. This position also supports ongoing NCQA activities, audits, regulatory initiatives, and other quality improvement projects.
Key Responsibilities- Review applicable NCQA, CMS, and state regulations and standards and ensure appropriate operational controls are in place.
- Identify compliance gaps and recommend or support implementation of corrective measures when needed.
- Perform ongoing sample case reviews to evaluate the quality and accuracy of Utilization Management decisions and documentation.
- Ensure clinical staff are correctly applying InterQual criteria, medical policies, and departmental guidelines.
- Review cases referred to Medical Directors to ensure referrals are appropriate and include relevant, complete clinical information needed to support medical necessity determinations.
- Conduct quality reviews of member letters to ensure documentation is clear, accurate, understandable, and compliant with regulatory requirements.
- Verify that clinical staff document appropriately within the medical management system to support accurate letter generation.
- Identify quality, compliance, and efficiency trends through audit findings and report findings to management.
- Support NCQA surveys, annual documentation preparation, maintenance activities, and other regulatory projects.
- Serve as a knowledgeable resource for internal and external stakeholders, providing timely and professional communication.
- Maintain strong attention to detail while managing multiple priorities and compliance requirements.
Qualifications:- Active and unrestricted Pennsylvania Registered Nurse (RN) license required.
- Minimum of 5 years of clinical nursing experience.
- BSN preferred.
- Previous experience with Utilization Management, Utilization Review, or Care Management strongly preferred.
- Moderate to strong knowledge of InterQual criteria required.
- Experience working with Utilization Management or medical management systems.
- Knowledge of NCQA, CMS, state regulatory requirements, and other healthcare compliance standards.
- Experience reviewing clinical documentation, medical necessity determinations, and/or regulatory member communications preferred.
- Excellent written and verbal communication skills with exceptional attention to detail.
- Strong analytical, problem-solving, organizational, and planning skills.
- Ability to provide constructive feedback while maintaining positive and productive working relationships.
- Proficiency with Microsoft Excel, PowerPoint, and Word.
- Ability to work effectively in a remote environment while managing competing priorities and deadlines.
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