Utilization Management RN (Prior Authorization)
Location: Must reside in PA, DE, or NJ License Required: Active PA RN license or compact including PA
Experience Required: UM RN with Prior Authorization
Experience Preferred: InterQual experience
Job Summary
The Utilization Management RN reviews members’ medical records to determine whether requested services are medically necessary. This includes evaluating clinical information, applying medical necessity criteria, and authorizing services when appropriate. When cases do not meet criteria, the RN prepares clinical summaries for Medical Director review.
Key Responsibilities
- Review medical records to determine medical necessity using clinical judgment and approved guidelines
- Apply InterQual, Medical Policy, Care Management Policy, and electronic references to make determinations
- Evaluate need for inpatient admission, continued stay, procedures, and ancillary services
- Communicate with servicing providers to clarify treatment plans and clinical details
- Refer cases that do not meet criteria to the Medical Director
- Identify discharge planning needs early and collaborate with case management
- Recommend alternative levels of care when appropriate
- Report utilization trends and potential issues to leadership
- Refer cases to Quality Management, Case Management, or Disease Management when indicated
- Confirm services are covered under the member’s benefit plan
- Ensure all decisions comply with state, federal, and accreditation requirements
- Meet required turnaround times and productivity standards
- Document all activities according to Care Management and Coordination policy
- Maintain accurate, timely data entry
Qualifications
- Active PA RN license or compact license including PA
- UM RN experience with Prior Authorization
- InterQual experience preferred
- Must reside in PA, DE, or NJ
