Utilization Review Nurse Corporate UM

Job description

Description

nPenn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

nToday at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

nEntity: Corporate Services

nDepartment: Corp Utilization Management

nLocation: Bala Cynwyd, PA/ remote

nSummary:

nThe Utilization Review Nurse is responsible for conducting timely and accurate utilization review activities to support appropriate patient status determination, medical necessity review, and compliance with regulatory and payer requirements. This role applies clinical expertise and evidence-based criteria to evaluate the appropriateness of admissions, continued stays, and resource utilization while promoting quality patient care and efficient use of healthcare resources.

nWorking within Penn Medicine's centralized Utilization Management department the Utilization Review Nurse collaborates with physicians, Physician Advisors, case management, revenue cycle, and interdisciplinary care teams to facilitate appropriate level-of-care determinations, authorization management, denial prevention, and compliance with federal, state, accreditation, and payer requirements.

nResponsibilities:

nnnConduct medical necessity reviews and patient status determinations using approved clinical criteria, regulatory requirements, and organizational policies.

n

nnPerform admission, concurrent, continued stay, and retrospective utilization reviews to ensure appropriate level of care and resource utilization.

n

nnManage payer authorization and notification processes to promote timely approvals and reduce financial risk.

n

nnIdentify and escalate cases that require secondary review, physician advisor involvement, or additional clinical documentation.

n

nnCollaborate with physicians, case managers, social workers, and interdisciplinary teams to support appropriate patient progression, discharge planning, and utilization management goals.

n

nnEnsure accurate and timely documentation of utilization review activities, authorization determinations, and payer communications within designated systems.

n

nnAssist with denial prevention activities through proactive identification of medical necessity, documentation, authorization, and patient status concerns.

n

nnMonitor and maintain compliance with CMS regulations, payer requirements, accreditation standards, organizational policies, and utilization management workflows.

n

nnPerforms duties in accordance with Penn Medicine and entity values, policies, and procedures

n

nnOther duties as assigned to support the unit, department, entity, and health system organization UPHS Organizational

n

n nCredentials:

nnnRegistered Nurse is required.

n

nnCertified Case Manager (CCM) or Accredited Case Manager (ACM) is preferred.

n

n nEducation or Equivalent Experience:

nnnBachelor's degree is required.

n

nn2+ years of Acute Hospital Care experience is required.

n

nnExperience with Interqual and MCG is preferred.

n

nnPrevious Utilization Management, Appeals, or Denials Management experience is preferred.

n

n nWe believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

nLive Your Life's Work

nWe are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

nREQNUMBER:

Worksite address

bala cynwyd, PA, 19004, US

Who can apply

Review the original listing for work authorization, qualifications and employer requirements.