Utilization Management RNWe're actively seeking qualified candidates for a Utilization Management Coordinator / RN opportunity supporting inpatient utilization management and care coordination.
This position is remote; however, candidates must reside in Pennsylvania, New Jersey, or Delaware to be eligible for potential conversion.
Key Requirements- Active Pennsylvania RN license required
- Post-acute care experience required
- Minimum of 3 years of acute-care clinical experience in a hospital or healthcare setting
- Utilization management and/or discharge planning experience strongly preferred
- Experience reviewing medical necessity, level of care, continued stay, and length of stay
- Experience working with clinical criteria such as InterQual or similar tools preferred
Position OverviewThe Utilization Management Coordinator / RN performs utilization management reviews for inpatient hospital admissions and works closely with providers, hospital case management teams, Medical Directors, members, and families to promote high-quality, cost-effective care.
This individual will evaluate medical necessity and continued stay, identify discharge planning needs, and help facilitate transitions to the most appropriate level and setting of care.
Responsibilities- Perform telephonic utilization management reviews for inpatient hospital admissions.
- Evaluate medical necessity, appropriate level of care, continued stay, and length of stay using established clinical criteria.
- Review treatment plans and collaborate with attending physicians and hospital utilization review teams regarding continued inpatient needs.
- Identify admissions that no longer meet established criteria and escalate cases to Medical Directors for review.
- Present relevant clinical information to Medical Directors regarding the member's condition, treatment plan, discharge needs, and potential home or post-acute care requirements.
- Proactively identify hospitalized members requiring discharge planning support.
- Collaborate with hospital case managers, physicians, members, and families to facilitate safe and timely transitions to the most appropriate setting.
- Evaluate potential alternative levels of care and post-acute services when appropriate.
- Refer members to Case Management and Disease Management programs when additional support is needed.
- Identify potential quality-of-care concerns, including delays in care, and escalate appropriately.
- Maintain timely and accurate documentation of utilization review activities and clinical determinations.
- Ensure utilization decisions comply with applicable state, federal, and accreditation requirements.
- Develop strong working relationships with providers while delivering a high level of customer service.
- Identify utilization trends and potential areas for improvement and communicate findings to leadership.
- Support provider education related to managed care and utilization management processes.
Qualifications- Active Pennsylvania Registered Nurse (RN) license required.
- Minimum of 3 years of acute-care clinical experience in a hospital or healthcare environment.
- Post-acute care experience required.
- Previous utilization management, utilization review, concurrent review, case management, and/or discharge planning experience preferred.
- Strong understanding of medical necessity, level-of-care determination, discharge planning, and transitions of care.
- Excellent clinical judgment and problem-solving skills.
- Strong written and verbal communication skills with the ability to effectively collaborate with physicians, providers, and multidisciplinary teams.
- Highly organized with the ability to manage multiple cases and competing priorities.
- Strong team-oriented approach and commitment to quality patient care.
#LI- Remote
