Remote Utilization Management RN – Pennsylvania

Utilization Management (RN) – Infusion Therapy Team Location: Remote

Department: Care Management & Coordination

License Required: Active Pennsylvania (PA) RN License

About The Role We are seeking an experienced Utilization Management (RN) to join our Infusion Therapy Team. In this fully remote role, you will leverage your clinical expertise and critical thinking skills to review medical records, evaluate treatment plans, and determine medical necessity for services in accordance with established guidelines and regulatory standards.

This position offers the opportunity to work independently while collaborating closely with providers, Medical Directors, and internal care teams to ensure members receive appropriate, high-quality, and cost-effective care.

Key Responsibilities

• Conduct comprehensive reviews of medical records, treatment plans, and clinical documentation to determine medical necessity.
• Apply evidence-based criteria including InterQual, Medical Policy, Care Management Policy, and other clinical resources to support determinations.
• Independently authorize services that meet medical necessity criteria; refer non-qualifying cases to the Medical Director for further review.
• Communicate directly with providers to obtain additional clinical information and clarify treatment plans when needed.
• Evaluate inpatient admissions, continued stays, procedures, and ancillary services for appropriateness and length of stay.
• Identify discharge planning needs early and collaborate with care teams to support safe transitions to appropriate levels of care.
• Serve as a patient advocate, helping members navigate the healthcare system and access necessary services.
• Ensure all decisions comply with federal, state, and accreditation regulations.
• Meet regulatory turnaround times and departmental productivity standards.
• Accurately document all case activities and maintain data integrity within care management systems.
• Identify utilization trends, potential quality concerns, or delays in care and escalate appropriately.
• Refer cases to Case Management, Disease Management, or Quality Management teams as indicated.

Qualifications

• Active Pennsylvania RN license (required).
• Strong clinical background with experience reviewing medical records and determining medical necessity.
• Experience utilizing InterQual or similar evidence-based medical necessity criteria preferred.
• Knowledge of utilization management, discharge planning, and care coordination processes.
• Excellent critical thinking, analytical, and documentation skills.
• Strong communication skills with the ability to collaborate effectively with providers and internal teams.
• Ability to work independently in a remote environment while meeting productivity and compliance standards.

What You’ll Bring

• Advanced clinical judgment and independent decision-making skills.
• Ability to balance regulatory compliance, clinical appropriateness, and cost-effective care.
• Commitment to high-quality member advocacy and service excellence.
• Strong organizational skills and attention to detail in a fast-paced environment.