Utilization Review Nurse

IntePros is an established, woman-owned, privately-held technology and business services consulting agency committed to building long-term relationships and helping more companies leverage the power of a more diverse workforce.

Utilization Management RN | Contract-to-Hire Location: Remote (Must reside in PA, NJ, or DE) Licensure Required: Active PA RN license or Nurse Licensure Compact including PA Department: Care Management & Utilization Review About the Role We’re hiring an experienced Utilization Review Nurse to join our Utilization Management team. This fully remote role is ideal for a clinically strong UM nurse who thrives in a fast-paced, review-driven environment and brings sound judgment, attention to detail, and a member-focused mindset.

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.