Utilization Review Nurse

Registered Nurse – Utilization Review

Location: Fully remote (PA RN License or Compact including PA Required), Must Reside in PA, NJ, or DE

Employment type: Contract to full-time hire

Position Overview:

We are seeking a skilled and detail-oriented Utilization Review RN with a valid PA license (or Compact) to join our team. This position is ideal for an RN with prior work in insurance utilization review.

Key Responsibilities:

• Conduct clinical reviews to determine medical necessity and appropriateness of care
• Apply evidence-based criteria to assess patient treatment plans and services
• Collaborate with healthcare providers and insurance partners to ensure efficient, quality patient care
• Document review findings accurately and in a timely manner
• Maintain compliance with internal and external regulatory standards

Required Qualifications:

• Active and unrestricted PA RN license (or Compact license including PA)
• 2-5+ years of prior experience in insurance utilization review
• Strong clinical judgment and knowledge of hospital workflows
• Proficient in using clinical review tools and electronic health records
• Familiarity with InterQual or Milliman criteria.