Job Description

Job Description

Pyramid Consulting is seeking a local contract nurse RN Utilization Review Level III for a local contract nursing job in Philadelphia, Pennsylvania.

• Specialty: Utilization Review
• Discipline: RN
• Start Date: 01/12/2026
• Duration: 13 weeks
• 37.5 hours per week
• Shift: 8 hours, days
• Employment Type: Local Contract

This position has potential to extend or convert into permanent and is fully Remote opportunity.

• Applies critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination.  Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.
• Utilizes the medical criteria of InterQual and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services.
• Note :  InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making.
• Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services.
• Reviews treatment plans/plan of care with provider for requested services/procedures, inpatient admissions or continued stay, clarifying medical information with provider if needed.
• Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation determination.
• Performs early identification of members to evaluate discharge planning needs.
• Collaborates with case management staff or physician to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.
• Reports potential utilization issues or trends to designated manager and recommendations for improvement.
• Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated to include delays in care.
• Appropriately refers cases to Case and Disease Management.
• Ensures request is covered within the member’s benefit plan.   
• Ensures utilization decisions are compliant with state, federal and accreditation regulations.
• Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests.
• Ensures that all key functions are documented via Care Management and Coordination Policy.
• Maintains the integrity of the system information by timely, accurate data entry.
• Performs additional duties assigned.

•\tActive PA Licensed RN or compact license that includes PA\n•\tBSN Preferred\n•\tMinimum of three (3) years of acute care clinical experience in a hospital or other health care setting\n•\tMedical management/precertification experience preferred.\n•\tPrior discharge planning and/or utilization management experience is desirable.\n

Supercharge your career with Pyramid Consulting. 

We are dedicated to accelerating growth, creating opportunities, and fostering an environment built on belonging, trust, and mutual respect. Our commitment is to help you find the best path to achieve your career goals.

As a global leader in workforce and technology solutions, Pyramid Consulting, Inc. partners with clients to navigate competitive and ever-changing markets. Our award-winning family of brands — Pyramid Talent, Celsior, and GenSpark — works seamlessly together, delivering integrated solutions through multiple delivery models across five continents and 25+ countries. Since our founding in 1996, we’ve supported 125+ Fortune 500 companies across all major industries by engaging 6,500+ consultants worldwide.

Join our talent network

Looking for a job that aligns with your skills and ambitions? Join our talent network and enhance your job search experience with access to a broad range of job opportunities tailored to your background and interests.

• Explore jobs: Visit our job portal to browse positions that suit your preferences. You can filter jobs by role, location, or industry to find the best match.
• Apply: Submit your application and upload your resume through our portal. Our recruiters will reach out to discuss your career goals and help connect you with the right opportunities.

Take the next step in your career journey with Pyramid Consulting, where we’re committed to helping you grow and succeed.

Job Tags

Similar Jobs