Clinical Review Nurse - Concurrent Review (Utilization Management)

Location: Remote within Pennsylvania or a Compact State; Monday through Friday, 8:00 AM to 5:00 PM

Pay range: $27.02–$48.55 per hour

Company

hirify.global provides healthcare services focused on connecting people with the care they need and improving health outcomes.

What you will do

• Perform concurrent reviews to assess member health, medical necessity, appropriate care settings, acuity, resource use, and length of stay.
• Review and document care findings, medical records, discharge plans, and actions in health management systems.
• Collaborate with Medical Affairs, Medical Directors, healthcare providers, and care management teams on medical determinations and referrals.
• Review transfer and discharge plans to support timely transitions between levels of care and facilities.
• Educate providers on utilization processes and provide feedback to leadership on opportunities to improve care levels and medical necessity decisions.

Requirements

• Active Pennsylvania or Compact State nursing license required.
• Licensed Practical Nurse or Registered Nurse credentials required.
• Graduate of an accredited nursing school or bachelor's degree in nursing.
• 2–4 years of related experience, including at least 2 years of acute care experience.
• Clinical knowledge sufficient to assess overall health, treatment needs, and appropriate levels of care.
• Knowledge of Medicare and Medicaid regulations and utilization management processes.

Nice to have

• Previous case management, utilization management, or utilization review experience.
• Experience with MCG and/or InterQual criteria.

Culture & Benefits

• Remote work arrangement with a weekday schedule.
• Health insurance, 401(k), stock purchase plans, and paid time off plus holidays.
• Tuition reimbursement and flexible work approaches.
• Equal opportunity workplace committed to diversity and inclusion.