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 Nurse Remote – Must Reside in the Tri-State Area (PA, NJ, or DE) Overview: We are seeking an experienced and detail-oriented Utilization Management RN. This position is ideal for a nurse with a strong background conducting inpatient or outpatient reviews in insurance environments.

Evaluate member clinical conditions through detailed medical record reviews to determine medical necessity for requested services. Apply advanced clinical judgment using InterQual, Care Management Policies, Medical Policies, and other resources to make utilization determinations. Contact servicing providers to clarify treatment plans and obtain additional medical information as needed. Review treatment plans and proposed procedures for medical appropriateness and ensure they align with benefit coverage and policy criteria. Refer cases not meeting established criteria to the Medical Director for further evaluation. Identify discharge planning needs early and collaborate with case management or physicians to ensure timely and appropriate transitions of care. Monitor and report utilization trends or potential quality issues, recommending process improvements where applicable. Maintain compliance with state, federal, and accreditation standards for utilization review and documentation. Meet or exceed turnaround and productivity goals for authorization requests. Accurately document all activities in accordance with Care Management and Coordination policies.