Utilization Review Nurse

Remote – Must Reside in the Tri-State Area (PA, NJ, or DE)

We are seeking an experienced and detail-oriented Utilization Management RN. This position is ideal for a nurse with a strong background conducting inpatient or outpatient reviews in insurance environments.

• Evaluate member clinical conditions through detailed medical record reviews to determine medical necessity for requested services.
• Apply advanced clinical judgment using Inter Qual, Care Management Policies, Medical Policies, and other resources to make utilization determinations.
• Contact servicing providers to clarify treatment plans and obtain additional medical information as needed.
• Review treatment plans and proposed procedures for medical appropriateness and ensure they align with benefit coverage and policy criteria.
• Refer cases not meeting established criteria to the Medical Director for further evaluation.
• Identify discharge planning needs early and collaborate with case management or physicians to ensure timely and appropriate transitions of care.
• Monitor and report utilization trends or potential quality issues, recommending process improvements where applicable.
• Maintain compliance with state, federal, and accreditation standards for utilization review and documentation.
• Meet or exceed turnaround and productivity goals for authorization requests.
• Accurately document all activities in accordance with Care Management and Coordination policies.

Experience

• Minimum 3 years of acute care clinical experience in an insurer setting.
• Excellent critical thinking, problem-solving, and communication skills.
• Strong organizational and time management abilities with attention to detail.
• Proficiency with Microsoft Word, Excel, Outlook, SharePoint, and Adobe; ability to learn new systems quickly.
• Ability to work effectively in a team-oriented, remote environment.
• Adaptable, resourceful, and comfortable with change and evolving technology.
• Committed to diversity, equity, and inclusion, and respectful collaboration with colleagues across all levels.

This is a great opportunity to leverage your clinical expertise in a non-bedside, remote role while continuing to make a meaningful impact on patient care. You’ll work alongside a supportive team that values collaboration, innovation, and professional growth.