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Utilization Management RN

1 month ago

Philadelphia, United States IntePros Full time

IntePros is seeking a Utilization Management RN for our healthcare client. This role requires the candidate to have significant experience in managed care, audit and oversight of utilization management, and case management. Additionally, the candidate must possess an unrestricted RN license to practice in either New Jersey (NJ) or Pennsylvania (PA). This role is on site 3 days a week In Center city Philadelphia.


Role Requirements:

  • Managed care experience
  • Audit and oversight experience in utilization management and case management
  • Unrestricted RN license in NJ or PA

Responsibilities:

  • Perform audits and conduct ongoing monitoring of delegated entities to ensure compliance with federal and state laws, as well as accreditation standards.
  • Review materials submitted for audits, including policies, files, program documents, and other relevant materials.
  • Analyze data related to vendor performance to identify opportunities for improvement.
  • Write audit reports and manage corrective action plans.
  • Present findings and recommendations to the Delegation Oversight Committee.
  • Conduct annual risk assessments to identify and evaluate delegation risks.
  • Collect and prepare documents in preparation for audits.
  • Actively participate in CMS program audits.
  • Possess knowledge of Part C Organization Determination guidelines and National Committee for Quality Assurance (NCQA) standards.

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