Case Manager – Utilization Management

Lehigh Valley Health Network

. Review all hospitalized patients and evaluate admission appropriateness using approved criteria .

Posted 10/28/2026full-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 care and financial outcomes.

Highest-signal resume keywords

Utilization Review ExperienceKnowledge of Utilization ManagementEvidence-Based Clinical Decision SupportLicensed Registered Nurse (RN)Knowledge of InterQual and/or MCG Criteria

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewPatient Class AssignmentUtilization ManagementAdmission Appropriateness AssessmentPerformance Improvement AssessmentWork Queue ProcessesDocumentation of AuthorizationsPatient Financial Status CoordinationReimbursement OptimizationPolicy Development

Soft Skills

Attention to DetailTeam CollaborationFlexibilityPositive AttitudeTime Management

Tools & Technologies

Precertification SystemsBilling SoftwareCoding SystemsPatient Access Tools

Certifications & Qualifications

Licensed Registered Nurse (RN), PennsylvaniaACM CertificationACMA CertificationCCM CertificationCMCN Certification

Industry Keywords

HIPAA ComplianceThird-Party Payer RequirementsPatient Class ChangesClinical ReviewsUtilization Management Criteria

About the role

Key responsibilities & impact

Review all hospitalized patients 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
Coordinate with precertification, appeals, patient access, billing, coding, and finance teams
Assess admission appropriateness using evidence-based criteria
Collaborate on complex cases, patient class assignment, and reimbursement optimization
Complete patient class changes as directed by physician advisors, attending providers, and payers
Document authorizations and downgrades
Participate in performance improvement assessment, implementation, and evaluation

Requirements

What you’ll need

Specialized Diploma in nursing
2 years of previous utilization review experience
2 years of knowledge of utilization management as it relates to third party payers
Ability to maintain strict HIPAA adherence and confidentiality of all 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
Proficiency with all work queue processes
Knowledge of evidence-based clinical decision support criteria
RN - Licensed Registered Nurse, State of Pennsylvania, upon hire
Preferred: Bachelor’s Degree in nursing
Preferred: Knowledge of InterQual and/or MCG criteria
Preferred: ACM, ACMA, CCM, and/or CMCN certifications in Pennsylvania upon hire

Benefits

Comp & perks

Full-time employment
Day shift schedule
Remote work in Pennsylvania
Equal employment opportunity
8-hour Monday–Friday work schedule with weekend and holiday coverage