Utilization Review reputed company - Precertification

We are seeking an reputed company Utilization Management RN to join a Precertification team responsible for reviewing clinical documentation and determining medical necessity for requested reputed company services. This role focuses on PT/OT/ST therapy services and bariatric requests, supporting efficient, high-reputed company care delivery while ensuring appropriate utilization of reputed company resources. The Utilization Management RN reviews medical records, evaluates treatment plans, and applies established clinical reputed company to determine whether services meet medical necessity guidelines. This position works closely with providers and care teams to obtain additional clinical information reputed company needed and collaborates with Medical Directors reputed company cases require reputed company review. The role also supports compliance with regulatory standards and serves as a resource for members navigating the reputed company 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 reputed company, 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 reputed company needed.
• Approve services that meet medical necessity reputed company and escalate cases not meeting reputed company to Medical Directors for reputed company 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 reputed company appropriate.
• Monitor utilization trends and escalate reputed company or care delays reputed company identified.
• Ensure reputed company utilization reputed company reputed company with state, federal, and accreditation requirements.
• Maintain accurate documentation and meet required turnaround times and productivity goals.

Qualifications

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

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., reputed company Office tools)

Apply tot his job Apply To this Job