Utilization Management Nurse

January 7, 2022
Philadelphia, PA
Job Type


Job Title: Utilization Management Nurse
Job Location: Philadelphia, PA
Job Duration: 6+ months

Job Summary:

Under the general supervision of the Sr. Director, Case Management the Utilization Management Nurse provides comprehensive assessment, coordination, implementation and reporting of complex clinical data. The Utilization Management Nurse assesses the patients plan of care and progress of the patient throughout an acute care admission. The intensity of assessment is situational and appropriate based on payer requirements. This position is accountable for the communication of the clinical services delivered to identified payers and agencies

Job Responsibilities:

  • Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third-party information.
  • Intervenes when determinations are not in alignment with clinical information, clinical criteria or third-party information to resolve the situation.
  • Documents all case management interventions in the current electronic system.
  • Monitors and updates accommodation codes and patient types (observation/inpatient), to ensure capture of status and level of care.
  • Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians. Recommends alternative care sites where appropriate.
  • Updates discharge list for last covered day. Calls discharge date to payer or submit discharge review.
  • All new admission reviews are to be completed within 1 business day.
  • Confirmation of pre-certification or authorization for admission.
  • InterQual Criteria is to be utilized with each new admission as well as with every denial.
  • Inform the case manager of any issues or plans noted in the documentation.
  • Self-Pay cases should be referred to Family Health Coverage Program (FHCP) and/or Social Work to determine if coverage is pending or if application for coverage has been made.

Required Education:

  • Nursing Diploma

Required Experience:

  • Minimum of five (5) year's experience as clinical nurse in an acute care setting.

Required Licenses:

  • Registered Nursing License in the Commonwealth of Pennsylvania
  • The COVID vaccine is required for this role.

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