About the job
Utilization Management (RN)Location: Remote – Must reside in PA, DE, or NJ
Licensure Requirement: Active Pennsylvania RN license or Nurse Licensure Compact (NLC) license that includes PA
Position Summary
The Care Management Coordinator (RN) is responsible for conducting comprehensive clinical reviews to determine the medical necessity of requested healthcare services. Through independent analysis of medical records and application of established clinical criteria, this role plays a critical part in ensuring appropriate utilization of healthcare services while maintaining regulatory compliance.
This position serves as both a clinical decision-maker and patient advocate, working closely with providers, Medical Directors, and internal care management teams to support safe, appropriate, and cost-effective care.
Key ResponsibilitiesClinical Review & Authorization
- Review medical records, including history and treatment documentation, to assess the medical necessity of services.
- Apply clinical judgment and advanced medical knowledge using:
- InterQual criteria
- Medical Policy
- Care Management Policies
- Electronic Desk References
- Determine appropriateness of:
- Inpatient admissions
- Continued stays and length of stay
- Procedures and ancillary services
- Independently authorize medically necessary services based on clinical review.
- Escalate cases that do not meet criteria to the Medical Director for further evaluation (role may approve but not deny care).
Provider & Care Coordination
- Contact servicing providers to:
- Clarify treatment plans and plans of care
- Obtain additional clinical information
- Discuss medical necessity of requested services
- Identify discharge planning needs early and collaborate with case management or physicians to support transition to the most appropriate care setting.
- Refer cases appropriately to:
- Case Management
- Disease Management
- Quality Management
- Care Management leadership
Utilization & Compliance
- Ensure all authorization decisions align with:
- Federal and state regulations
- Accreditation standards
- Member benefit plans
- Meet or exceed regulatory turnaround times and departmental productivity goals.
- Report utilization trends, delays in care, or potential issues to leadership with recommendations for improvement.
- Maintain accurate, timely documentation and data entry in care management systems.
Advocacy & Member Support
- Serve as a patient advocate, assisting members in navigating the healthcare system and accessing appropriate services.
QualificationsEducation & Licensure
- Active RN license (PA license or NLC including PA required)
- BSN preferred
Experience
- Minimum 3 years of Medical-Surgical clinical experience in a hospital or healthcare setting
- Experience in discharge planning, utilization management, or precertification preferred
- Experience using InterQual and/or Milliman criteria preferred
Knowledge, Skills & Abilities
- Strong clinical assessment and critical thinking skills
- Excellent communication and interpersonal skills when working with providers and interdisciplinary teams
- Ability to prioritize, work independently, and meet productivity standards
- Detail-oriented with strong documentation skills
- Adaptable and comfortable working in evolving healthcare environments
- Proficient in Microsoft Office (Word, Excel, Outlook, SharePoint) and able to learn new systems quickly
- Strong understanding of current medical practice trends and utilization management principles
