Entry Level Utilization Review Nurse Jobs

INTRODUCTION

We are seeking an experienced Care Management Coordinator to join our Infusion Therapy team. This role is responsible for performing utilization management reviews to determine the medical necessity of requested healthcare services, ensuring members receive appropriate, evidence-based care while maintaining compliance with regulatory and accreditation standards. This position is ideal for a clinically strong RN who thrives in a collaborative environment, enjoys critical thinking, and is passionate about improving patient outcomes through high-quality utilization management.

ROLE AND RESPONSIBILITIES

• Conduct medical necessity reviews for infusion therapy services using InterQual, medical policies, and evidence-based clinical guidelines.
• Review medical records, treatment plans, and clinical documentation to authorize medically necessary services.
• Collaborate with physicians and providers to obtain additional clinical information and clarify treatment plans when needed.
• Present cases that do not meet medical necessity criteria to the Medical Director for final determination.
• Identify discharge planning needs and collaborate with case management to support appropriate transitions of care.
• Ensure authorization decisions comply with federal, state, and accreditation requirements while meeting established turnaround times.
• Identify utilization trends, quality concerns, and opportunities for process improvement.
• Accurately document all clinical reviews and maintain the integrity of care management systems.
• Serve as a clinical resource and advocate for members navigating the healthcare system.

BASIC QUALIFICATIONS

• Active Pennsylvania Registered Nurse (RN) license required.
• Previous experience in Utilization Management, Care Management, Case Management, or Prior Authorization.
• Strong understanding of medical necessity review, healthcare regulations, and evidence-based clinical criteria.
• Experience utilizing InterQual or similar medical necessity guidelines strongly preferred.
• Excellent critical thinking, clinical assessment, communication, and documentation skills.
• Ability to independently prioritize a high-volume workload while meeting regulatory turnaround times.

PREFERRED QUALIFICATIONS

• Infusion therapy, specialty pharmacy, oncology, or complex care management.
• Managed care, health plan, or payer experience.
• Experience reviewing inpatient, outpatient, or specialty service authorizations.

This is an excellent opportunity for an experienced RN who enjoys combining clinical expertise with analytical decision-making to ensure members receive timely, appropriate, and high-quality care while supporting organizational quality and compliance initiatives.