Utilization Review Nurse
Overview
Penn Medicine seeks a skilled Utilization Review Nurse to lead authorization processes using InterQual criteria. This role ensures medical necessity and optimizes patient care while reducing costs. You will collaborate with physicians and support teams to improve outcomes.
What You'll Do11
- 1Lead utilization reviews for authorization concurrent and discharge services
- 2Apply InterQual criteria to assess medical necessity and appropriateness
- 3Collaborate with physicians and multidisciplinary teams for timely care
- 4Document medical care accurately for third-party payors
- 5Identify trends in resource utilization and care delays
- 6Intervene to avoid plan of care barriers and non-appealable denials
- 7Mentor new hires and promote professional growth
- 8Coordinate clinical information with payors for optimal reimbursement
- 9Monitor admission severity and intervene to avoid LOS readmissions
- 10Assess patient progress against expected in-house course
- 11Consult with physician advisors to refine care plans
Requirements11
- 1Registered Nurse - PA required
- 2Certified Case Manager
- 3Associate degree in Nursing or equivalent experience
- 4Bachelor of Arts or Science in Nursing required
- 51+ year utilization review experience
- 6Experience with InterQual criteria application
- 7Strong communication skills for cross-functional collaboration
- 8Knowledge of hospital accreditation standards
- 9Ability to manage complex care transitions
- 10Proficiency in documentation systems
- 11Commitment to evidence-based practice
Salary Insight
Salary not disclosed in listing
Location
Required Skills
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