Post Acute Utilization Manager

Post‑Acute Utilization Manager (Remote – Tri‑State Area Only)

Target Start Date: June 1
Schedule: Monday–Friday, Day Shift
Type: Temporary with Potential for Permanent Hire
Location Requirement: Candidate must reside in PA, NJ, or DE

Position Summary

The Post‑Acute Utilization Manager conducts telephonic reviews of inpatient and post‑acute admissions to determine medical necessity, appropriate level of care, and opportunities for timely discharge planning. Under the direction of the Care Management & Coordination Supervisor, this role ensures efficient, high‑quality use of healthcare resources while collaborating with hospital teams, physicians, members, and families. Strong knowledge of InterQual and post‑acute care settings is essential.

Key Responsibilities

Utilization Management — Perform telephonic or onsite review of inpatient and post‑acute admissions to determine medical necessity and appropriate level of care.

InterQual Criteria Review — Apply medical necessity criteria to evaluate inpatient, continued stay, and length‑of‑stay requirements.

Care Coordination — Direct care to the most appropriate setting while maintaining quality and regulatory compliance.

Physician Collaboration — Communicate with attending physicians to clarify treatment plans and validate medical necessity.

Medical Director Case Presentation — Present cases not meeting criteria and provide clinical summaries and discharge considerations.

Discharge Planning — Identify discharge needs early and collaborate with hospital case managers, physicians, and families.

Case & Disease Management Referrals — Identify members appropriate for additional care management programs.

Quality Issue Identification — Recognize delays or quality concerns and escalate to Quality Management or leadership.

Data Integrity — Maintain accurate, timely documentation in compliance with state, federal, and accreditation standards.

Provider Relations — Build strong relationships with providers and deliver exceptional customer service.

Trend Reporting — Report utilization trends and recommend process improvements.

Provider Education — Participate in educating providers on managed care processes.

Required Qualifications:

Active RN license in PA or Compact RN license including PA.

Minimum 3 years of acute care RN experience in a hospital setting.

Utilization Management experience in the post‑acute setting, including medical necessity review and InterQual.

Post‑Acute Care experience in at least one of the following settings (must be clearly indicated on resume):

Skilled Nursing Facilities (SNFs)

Inpatient Rehabilitation (not behavioral health)

Home Health

Long‑Term Acute Care Hospitals (LTACHs)