Utilization Review Nurse
IntePros provided pay range
This range is provided by IntePros. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.
Base pay range
Job Title: Utilization Review Nurse
Position Type: Part-Time (Every other weekend - Saturday and Sunday, totaling 30 hours per month)
Training Requirement: Candidates must be available M-F during typical business hours for a 4-week training period.
Job Summary: The Care Management Coordinator is responsible for evaluating members' clinical conditions through the review of medical records to determine the medical necessity of services. This role involves direct interaction with providers to obtain additional clinical information when necessary. The Care Management Coordinator has the authority to authorize medically necessary services based on their review but must refer cases that do not meet established criteria to the Medical Director. This role ensures regulatory compliance and acts as a patient advocate and resource for navigating the healthcare system.
Key Responsibilities:
- Apply critical thinking and judgment skills based on advanced medical knowledge to determine medical appropriateness using specified resources and guidelines.
- Use InterQual criteria and Medical Policy to establish the need for inpatient stays, procedures, and ancillary services.
- Contact providers to discuss treatment plans and clarify medical needs.
- Review and clarify treatment plans for requested services, inpatient admissions, or continued stays.
- Refer cases not meeting established criteria to the Medical Director for further evaluation.
- Identify members needing discharge planning early and collaborate with case management staff or physicians to facilitate discharge to the appropriate setting.
- Report potential utilization issues or trends and provide recommendations for improvement.
- Refer cases to the Quality Management Department and/or Care Management and Coordination Manager as needed.
- Ensure requests are covered within the members' benefit plans and comply with state, federal, and accreditation regulations.
- Meet regulatory turnaround times and departmental productivity goals.
- Maintain accurate and timely data entry in the system.
Qualifications:
Education:
- Active PA Licensed RN
- BSN preferred
Experience:
- Minimum of three (3) years of acute care clinical experience in a hospital or healthcare setting.
- Prior discharge planning and/or utilization management experience is desirable.
- Medical management/precertification experience preferred.
Knowledge & Skills:
- Exceptional communication, problem-solving, and interpersonal skills.
- Strong ability to set priorities and achieve results.
- Team player with the ability to build team spirit and interdepartmental rapport.
- Open to change and comfortable with new ideas and methods.
- Respectful of workforce diversity and colleagues.
- Excellent organizational and prioritizing skills.
- Effective time management.
- Knowledgeable about current medical practice trends.
- Proficient in Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs, with the ability to learn new systems.
-
Seniority level
Associate -
Employment type
Part-time -
Job function
Management -
Industries
Hospitals and Health Care and Insurance
Referrals increase your chances of interviewing at IntePros by 2x
See who you knowGet notified about new Utilization Review Nurse jobs in Philadelphia, PA.
Sign in to create job alertSimilar jobs
People also viewed
-
Licensed Marriage & Family Therapist (LMFT)
Licensed Marriage & Family Therapist (LMFT)
-
Field Case Manager
Field Case Manager
-
Field Case Manager
Field Case Manager
-
Licensed Psychiatric Nurse Practitioner
Licensed Psychiatric Nurse Practitioner
-
Licensed Psychiatric Nurse Practitioner
Licensed Psychiatric Nurse Practitioner
-
Licensed Clinical Social Worker (LCSW) - Teletherapy
Licensed Clinical Social Worker (LCSW) - Teletherapy
-
Senior Therapeutic Area Specialist - Cardiovascular Community, Cherry Hill, NJ
Senior Therapeutic Area Specialist - Cardiovascular Community, Cherry Hill, NJ
-
Territory Manager - Camden
Territory Manager - Camden
-
Clinical Account Manager
Clinical Account Manager
Similar Searches
-
Document Control Coordinator jobs
-
Document Control Manager jobs
-
Document Management Specialist jobs
-
Scheduling Coordinator jobs
-
Software Implementation Specialist jobs
-
Data Modeler jobs
-
Data Coordinator jobs
-
Documentation Manager jobs
-
Oracle Developer jobs
-
Manufacturing Quality Engineer jobs
-
Public Health Specialist jobs
Explore collaborative articles
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
Explore More