Seeking an experienced Utilization Management RN to support inpatient utilization review and care coordination in a remote environment. This role is responsible for reviewing hospital admissions, determining medical necessity, and helping ensure members receive care in the most appropriate setting while supporting timely discharge planning and efficient use of healthcare resources. Post-acute care experience is required, along with an active Pennsylvania RN license. Remote (Must reside in PA, NJ, or DE)

Key Responsibilities

• Perform telephonic utilization review for inpatient admissions and continued stays using established clinical criteria.
• Evaluate medical necessity and determine appropriate level of care and length of stay.
• Collaborate with physicians, hospital utilization review teams, and care management staff to clarify treatment plans.
• Identify cases that no longer meet criteria and escalate to Medical Directors for further review when appropriate.
• Support early discharge planning and coordinate transitions to appropriate post-acute care settings.
• Identify cases for case management or disease management programs.
• Maintain accurate documentation and ensure compliance with state, federal, and accreditation regulations.

Qualifications

• Active Pennsylvania RN license required
• Minimum 3 years of acute care hospital experience
• Post-acute care experience required
• Prior utilization management, discharge planning, or case management experience preferred

Skills

• Strong clinical judgment, communication, problem-solving, and organizational skills with the ability to work independently in a remote, high-volume review environment