Utilization Management RN – Remote (Tri-State)

About the role

We are seeking a Registered Nurse to join our remote Utilization Management team serving the PA, NJ, and DE tri‑state area. The RN will review inpatient admissions, ensure medical necessity, and support safe, efficient transitions of care while collaborating with providers, patients, and families.

Key responsibilities

• Conduct inpatient utilization reviews (telephonic and/or onsite) to assess medical necessity and appropriate level of care.
• Apply established clinical criteria to evaluate admissions, continued stay, and length of stay.
• Partner with physicians, hospital staff, and care teams to align on treatment plans and care appropriateness.
• Escalate cases that do not meet criteria to Medical Directors with clear clinical summaries.
• Lead early discharge planning and collaborate with case management, patients, and families.
• Identify members who would benefit from case or disease management programs.
• Ensure accurate documentation and compliance with regulatory and accreditation standards.
• Build strong provider relationships and contribute to a high standard of member and provider experience.
• Monitor trends, flag improvement opportunities, and support process optimization and provider education.

Required profile

• Active RN license (Compact or PA required).
• Experience in utilization management and/or discharge planning.
• Strong clinical judgment with the ability to make informed, timely decisions.
• Excellent communication and collaboration skills across multidisciplinary teams.
• Ability to manage multiple priorities in a fast‑paced, deadline‑driven environment.
• Comfort working with clinical systems and medical necessity criteria tools.

Required skills

What we offer

• Fully remote work with strong team collaboration.
• High‑impact role influencing patient outcomes and care efficiency.
• Opportunity to work closely with providers and leadership in a dynamic care environment.
• Path for long‑term growth and potential conversion to a permanent position.