Utilization Management Nurse Specialist

2 days ago


Philadelphia, Pennsylvania, United States Health Partners Plans Full time
Utilization Management Nurse

About the Role:

We are seeking a skilled and detail-oriented Utilization Management Nurse to join our team at Health Partners Plans. As a Utilization Management Nurse, you will play a critical role in ensuring cost-effective and quality utilization management in the acute level of care setting for the pediatric and adult population in the post-acute inpatient setting.

Key Responsibilities:

  • Review and track emergency admissions to identify appropriate levels of care for acute and post-acute inpatient services.
  • Perform concurrent review and/or admission review on all hospital admissions using InterQual criteria guidelines.
  • Track assigned cases for timely reviews/updates and decisions as reflected in case documentation.
  • Request and review medical records to identify appropriate acute care days and approve or refer questionable days to the medical director for decision.
  • Function as a liaison between providers, members, and interdepartmentally.
  • Serve as a resource for physicians, PCPs, Utilization Review departments, and all medical providers.
  • Identify trends that impact utilization at hospitals during the review process and help resolve them.
  • Maintain departmental and regulatory timeframes for utilization decisions.
  • Contribute to the development and enhancement of documentation, tracking tools, and process flows.
  • Maintain collaborative and effective cross-functional training within the Utilization Management Department.
  • Perform after-hours on-call coverage.
  • Participate in relevant work groups and provide deliverables as necessary.
  • Successful and timely completion of assignments in accordance with departmental and Company operational objectives.

Requirements:

  • Licensed Registered Nurse, with an active license to practice professional nursing in the Commonwealth of Pennsylvania.
  • 2 years of medical/surgical, utilization review, and emergency room experience.
  • BSN preferred.
  • Thorough understanding of managed care systems and utilization review criteria.
  • Recent experience in a hospital, insurance company, or independent review company in utilization, quality review, or case management.
  • Knowledge of health insurance, including Medicare, Medicaid, and managed care.
  • Excellent telephone and verbal/written communication skills.
  • Proficient use of Microsoft Office suite (Word, PowerPoint, Excel) required.

What We Offer:

  • Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing.
  • Flextime and Work-at-Home Options.
  • Benefits & Wellness Program, including generous Time Off.
  • Impact on the communities we serve.


  • Philadelphia, Pennsylvania, United States destinationone Consulting Full time

    Job Title: Drug Utilization Review SpecialistDestinationone Consulting is seeking a highly skilled Drug Utilization Review Specialist to join our team. As a key member of our healthcare recruitment team, you will play a critical role in evaluating medication use patterns to promote safe and effective medication therapy.Key Responsibilities:Conduct...


  • Philadelphia, Pennsylvania, United States Open Systems Technologies Full time

    Job Title: Utilization Management RNWe are seeking a skilled Utilization Management RN to join our team at Open Systems Technologies. As a Utilization Management RN, you will play a critical role in ensuring compliance with federal and state laws, accreditation standards, and regulatory requirements.Responsibilities:Conduct audits and ongoing monitoring of...


  • Philadelphia, Pennsylvania, United States Open Systems Technologies Full time

    Job Title: Utilization Management RNWe are seeking a skilled Utilization Management RN to join our team at Open Systems Technologies. As a Utilization Management RN, you will play a critical role in ensuring compliance with federal and state laws, accreditation standards, and company policies.Key Responsibilities:Conduct audits and ongoing monitoring of...


  • Philadelphia, Pennsylvania, United States QTC Management, Inc. Full time

    Job SummaryWe are seeking a highly skilled Provider Utilization Coordinator Senior to join our team at QTC Management, Inc. The successful candidate will be responsible for coordinating with IPA providers and operations to ensure effective communication and utilization of reports and tools.Key ResponsibilitiesConsistent and effective communication with IPA...


  • Philadelphia, Pennsylvania, United States destinationone Consulting Full time

    Job Overviewdestinationone Consulting is a leading recruitment agency specializing in diverse sectors, including Healthcare, Health Tech, Government, Municipalities, Non-Profits, Legal, and Public Accounting. We are building a comprehensive database of opportunities in these fields. By applying, you ensure our recruiters can efficiently match you with...

  • Nurse Care Specialist

    1 month ago


    Philadelphia, Pennsylvania, United States Professional Case Management Full time

    Professional Case Management is a leader in home healthcare, seeking a skilled Registered Nurse to provide in-home services to clients. As a Nurse Care Specialist, you will have the opportunity to make a difference in the lives of our clients, while enjoying the flexibility of creating your own schedule.**Key Responsibilities:*** Provide high-quality patient...

  • Clinical Care Manager

    1 month ago


    Philadelphia, Pennsylvania, United States Community Behavioral Health. Full time

    Job SummaryCommunity Behavioral Health is seeking a highly skilled Clinical Care Manager to join our team. As a Clinical Care Manager, you will play a critical role in ensuring that our members receive timely access to quality, medically necessary behavioral health services.Key ResponsibilitiesUtilization Management: Conduct utilization review activities,...


  • Philadelphia, Pennsylvania, United States Universal Health Services, Inc. Full time

    Job Title: Clinical Utilization ManagerAt Universal Health Services, Inc., we are seeking a highly skilled Clinical Utilization Manager to join our team. As a key member of our healthcare team, you will play a critical role in ensuring the highest quality of care for our patients.Responsibilities:Review patient medical records to determine the severity of...


  • Philadelphia, Pennsylvania, United States Community Behavioral Health Full time

    Job Title: Clinical Care ManagerThe Clinical Care Manager is a critical role within our organization, responsible for ensuring that our members receive timely access to quality, medically necessary behavioral health services. As a Clinical Care Manager, you will be responsible for conducting utilization review activities, population management, cross-system...


  • Philadelphia, Pennsylvania, United States Community Behavioral Health. Full time

    Job SummaryWe are seeking a highly skilled Clinical Care Manager to join our team at Community Behavioral Health. The successful candidate will be responsible for conducting utilization review activities, population management, cross-system consultation, provider management, and treatment quality monitoring. This role requires a strong clinical background,...


  • Philadelphia, Pennsylvania, United States Highmark Health Full time

    Job SummaryWe are seeking a skilled Nurse Triage Specialist to join our team at Highmark Health. As a key member of our healthcare team, you will be responsible for providing remote nursing triage to patients across various populations, including infants, the elderly, and those with behavioral needs.Key ResponsibilitiesProvide comprehensive nursing...


  • Philadelphia, Pennsylvania, United States Nandail Property Management Full time

    Job Title: Maintenance TechnicianCompany Overview:Nandail Property Management is a leading provider of property management and facility maintenance solutions for residential and commercial properties. Our commitment to delivering exceptional services and upholding the highest standards of quality and professionalism sets us apart in the industry.Position...

  • Payroll Specialist

    3 weeks ago


    Philadelphia, Pennsylvania, United States FosterThomas HR Management and Consulting Full time

    Payroll Specialist Job DescriptionFosterThomas HR Management and Consulting is seeking a skilled Payroll Specialist to join our team. As a Payroll Specialist, you will be responsible for the accurate and timely processing of company payrolls, ensuring compliance with tax laws and regulations.Key Responsibilities:Process payroll for salaried exempt,...


  • Philadelphia, Pennsylvania, United States Public Health Management Corporation Full time

    Job Overview:The Public Health Management Corporation (PHMC) is seeking a skilled Mental Health Care Specialist to join our team. As a key member of our healthcare team, you will provide high-quality mental health services to adults in community-based nurse-managed health centers, serving diverse and underserved populations.Responsibilities:Conduct...


  • Philadelphia, Pennsylvania, United States Federal Emergency Management Agency Full time

    Job SummaryThe Federal Emergency Management Agency (FEMA) is seeking a highly skilled Emergency Management Specialist to join our team. As a key member of our Response Division, you will play a critical role in coordinating disaster logistics and resource management efforts.Key ResponsibilitiesCollaborate with Response Division branches, other Region 3...

  • Clinical Care Manager

    4 weeks ago


    Philadelphia, Pennsylvania, United States Community Behavioral Health. Full time

    Job Title: Clinical Care ManagerCommunity Behavioral Health (CBH) is seeking a highly skilled Clinical Care Manager to join our team. As a Clinical Care Manager, you will play a critical role in ensuring that our members receive timely access to quality, medically necessary behavioral health services.Key Responsibilities:Conduct utilization review...


  • Philadelphia, Pennsylvania, United States EHR Encore Health Resource Full time

    Job Title: Clinical Nurse SpecialistJoin our team of experienced healthcare professionals as a Clinical Nurse Specialist. In this role, you will have the opportunity to utilize your clinical nursing expertise to support the implementation of medical devices in a hospital setting.Key Responsibilities:Collaborate with local nursing staff to ensure seamless...


  • Philadelphia, Pennsylvania, United States Niagara Bottling Full time

    Niagara Bottling is seeking a skilled Utilities Technician to join their team. As a key member of the facilities maintenance team, you will be responsible for maintaining, inspecting, and operating utility systems, including compressed air, process water, product water, and electrical distribution. Your duties will also include maintaining a clean and safe...


  • Philadelphia, Pennsylvania, United States Niagara Bottling Full time

    Niagara Bottling **Job Summary** As a Utilities Technician at Niagara Bottling, you will be responsible for maintaining, inspecting, and operating utility systems, including compressed air, process water, product water, and electrical distribution. Your primary goal will be to ensure a safe and clean work environment in all areas related to utility rooms,...


  • Philadelphia, Pennsylvania, United States Community Behavioral Health. Full time

    Job SummaryCommunity Behavioral Health (CBH) is seeking a highly skilled Clinical Care Management Specialist to join our team. As a Clinical Care Management Specialist, you will play a critical role in providing high-intensity care management to children and families in need. This is a unique opportunity to make a meaningful difference in the lives of our...