Entity:

Corporate Services Department:

Corp Utilization Management Location:

Bala Cynwyd, PA/ remote

Summary:

The 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. Working 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.

Responsibilities:

Conduct medical necessity reviews and patient status determinations using approved clinical criteria, regulatory requirements, and organizational policies. Perform admission, concurrent, continued stay, and retrospective utilization reviews to ensure appropriate level of care and resource utilization. Manage payer authorization and notification processes to promote timely approvals and reduce financial risk. Identify and escalate cases that require secondary review, physician advisor involvement, or additional clinical documentation. Collaborate with physicians, case managers, social workers, and interdisciplinary teams to support appropriate patient progression, discharge planning, and utilization management goals. Ensure accurate and timely documentation of utilization review activities, authorization determinations, and payer communications within designated systems. Assist with denial prevention activities through proactive identification of medical necessity, documentation, authorization, and patient status concerns. Monitor and maintain compliance with CMS regulations, payer requirements, accreditation standards, organizational policies, and utilization management workflows. Performs duties in accordance with Penn Medicine and entity values, policies, and procedures Other duties as assigned to support the unit, department, entity, and health system organization

UPHS Organizational Credentials:

Registered Nurse is required. Certified Case Manager (CCM) or Accredited Case Manager (ACM) is preferred.

Education or Equivalent Experience:

Bachelor's degree is required. 2+ years of Acute Hospital Care experience is required. Experience with Interqual and MCG is preferred. Previous Utilization Management, Appeals, or Denials Management experience is preferred. We 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. Live Your Life's Work We are an Equal Opportunity employer. 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