Case Manager – Utilization Management

Lehigh Valley Health Network

. Review all hospital admissions and evaluate admission appropriateness using approved criteria .

Posted 9/17/2026part-timeRemote • Pennsylvania • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Clinical Review processes, ensuring compliance with third-party payer requirements and adherence to HIPAA regulations. Proficient in evidence-based clinical decision support criteria and skilled in collaborating with multidisciplinary teams to optimize patient class assignments and departmental efficiency.

Highest-signal resume keywords

Utilization ManagementClinical ReviewEvidence-Based CriteriaRN - Licensed Registered NurseHIPAA Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ReviewPatient Class AssignmentClinical Decision SupportWork Queue ProcessesPerformance Improvement

Soft Skills

Attention to DetailTeam CollaborationFlexibilityPositive AttitudeTime Management

Tools & Technologies

InterQualMCG Criteria

Certifications & Qualifications

ACMACMACCMCMCN

Industry Keywords

Third Party Payer RequirementsPatient AccessBillingCodingPHI Confidentiality

About the role

Key responsibilities & impact

Review all hospital admissions and evaluate admission appropriateness using approved criteria
Ensure appropriate inpatient or outpatient patient class assignment and compliance with third party payer requirements
Educate staff on appropriate level of care assignment, patient class, and utilization management
Provide timely, accurate, and thorough clinical reviews for patient class decisions
Develop and implement methods, policies, and procedures to improve departmental efficiency
Partner with unit-based care managers regarding patient financial status, diagnosis, and discharge needs
Collaborate with precert/preservices, appeals, patient access, billing, coding, and finance teams
Complete clinical reviews using evidence-based criteria
Collaborate with management, peers, and colleagues to facilitate patient class assignment, resolve complex cases, and maximize reimbursement
Perform patient class changes as directed by the physician advisor, attending provider, and/or payer
Document authorizations and downgrades according to policy
Participate in performance improvement activities, including assessment, implementation, and evaluation of processes

Requirements

What you’ll need

Specialized Diploma in nursing
2 years of previous utilization review experience
Knowledge of utilization management as it relates to third party payers
Ability to maintain strict HIPAA adherence and confidentiality of PHI
Ability to work in a team environment and demonstrate flexibility
Attention to detail and positive attitude
Ability to complete assignments accurately and timely while managing multiple responsibilities and priorities
Proficiency with all work queue processes
Knowledge of evidence-based clinical decision support criteria
RN - Licensed Registered Nurse, Pennsylvania state license, upon hire
Preferred: Bachelor’s Degree in nursing
Preferred: Knowledge of InterQual and/or MCG criteria
Preferred: ACM, ACMA, CCM, or CMCN certification with Pennsylvania certification/credential requirements upon hire

Benefits

Comp & perks

Equal opportunity employment
Educational programs and/or social activities
Benefits are referenced as part of the employer's personnel programs, but no specific benefit details are provided