Pennsylvania Licensed Registered Nurse

To support a remote contract opportunity, a Pennsylvania Licensed Registered Nurse will review medical records to assess clinical conditions, determine medical necessity for services, and collaborate with healthcare providers while ensuring regulatory compliance. Key responsibilities Apply critical thinking and medical knowledge to assess cases and determine medical appropriateness using established guidelines Collaborate with providers to clarify treatment plans and escalate non-qualifying cases to the Medical Director Ensure compliance with state, federal, and accreditation regulations while maintaining accurate documentation and data entry Required qualifications Current, active, and unrestricted Pennsylvania Registered Nurse licensure Three years of clinical, case management, or disease management experience Utilization management experience in either outpatient or inpatient settings Minimum of three years of acute care clinical experience in a healthcare setting Prior discharge planning and/or utilization management experience is desirable