Job Description

Registered Nurse (RN) | Utilization Review
Location: Pennsylvania
Agency: Pyramid Consulting, Inc.
Pay: Competitive weekly pay (inquire for details)
Start Date: ASAP

About the Position

Key Responsibilities

• 100% REMOTE role but candidate has to be in (PA, NJ or DE)
• Equipment will be provided
• Perform utilization management reviews for inpatient admissions through onsite or telephonic assessment.
• Apply established medical necessity criteria to determine inpatient admission, continued stay, and appropriate length of stay.
• Evaluate cases to ensure care is delivered in the most appropriate and cost-effective setting while maintaining quality.
• Communicate with attending physicians to clarify treatment plans, medical necessity, and the need for continued inpatient care.
• Identify admissions that no longer meet established criteria and refer cases to Medical Directors for further review.
• Present cases to Medical Directors with relevant clinical information, including potential discharge and home-care needs.
• Identify hospitalized members early and assess their discharge planning and care coordination needs.
• Collaborate with hospital case managers, physicians, members, and families to identify appropriate alternative care settings and support timely discharge.

Requirements

Requirements

• 100% REMOTE role but candidate has to be in (PA, NJ or DE)
• Equipment will be provided
• Registered Nurse (RN) license with clinical healthcare experience.
• Strong knowledge of  Utilization Management (UM), Case Management, and Care Coordination .
• Experience reviewing medical necessity, inpatient admissions, continued stays, and length of stay .
• Knowledge of Milliman Care Guidelines (MCG), InterQual , or other evidence-based medical necessity criteria.
• Strong clinical assessment and critical-thinking skills .
• Ability to review medical records and identify appropriate level of care and discharge needs .
• Experience with discharge planning and care transitions .
• Strong communication skills for working with physicians, hospital case managers, patients, families, and Medical Directors .
• Ability to identify and escalate quality-of-care issues and utilization concerns .
• Knowledge of managed care principles, healthcare regulations, and accreditation requirements .
• Strong documentation, data-entry, and computer/EMR skills .
• Ability to work independently in a telephonic or onsite environment .
• Strong organization, time management, and attention to detail .
• Ability to manage multiple cases and meet productivity and turnaround-time requirements .

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