Utilization Review Nurse - Precertification

We are seeking an experienced Utilization Management RN to join a Precertification team responsible for reviewing clinical documentation and determining medical necessity for requested healthcare services. This role focuses on PT/OT/ST therapy services and bariatric requests, supporting efficient, high-quality care delivery while ensuring appropriate utilization of healthcare resources. The Utilization Management RN reviews medical records, evaluates treatment plans, and applies established clinical criteria to determine whether services meet medical necessity guidelines. This position works closely with providers and care teams to obtain additional clinical information when needed and collaborates with Medical Directors when cases require further review. The role also supports compliance with regulatory standards and serves as a resource for members navigating the healthcare system . Candidates must be residing in PA, NJ, or DE.

Responsibilities

• Review medical records and clinical documentation to determine medical necessity for requested services.
• Apply established clinical guidelines, including InterQual Criteria, medical policy, and care management policies.
• Evaluate requests for therapy services, inpatient admissions, procedures, and ancillary services.
• Communicate with providers to clarify treatment plans and obtain additional clinical information when needed.
• Approve services that meet medical necessity criteria and escalate cases not meeting criteria to Medical Directors for further review.
• Identify discharge planning opportunities and collaborate with care teams to support transitions to appropriate care settings.
• Refer members to case management or disease management programs when appropriate.
• Monitor utilization trends and escalate quality or care delays when identified.
• Ensure all utilization decisions comply with state, federal, and accreditation requirements.
• Maintain accurate documentation and meet required turnaround times and productivity goals.

Qualifications

• Active Pennsylvania RN license or Nurse Licensure Compact license including PA
• Minimum 3 years of acute care clinical experience in a hospital or healthcare setting
• BSN
• Prior utilization management, precertification, or discharge planning experience
• Experience applying clinical review guidelines or medical necessity criteria

Key Skills

• Strong clinical judgment and analytical review of medical documentation
• Excellent communication and collaboration with providers and care teams
• Highly organized with strong time management and prioritization skills
• Ability to work independently in a remote, high-volume review environment
• Proficiency with common business and care management systems (e.g., Microsoft Office tools)

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