Utilization Management Associate Jobs in Philadelphia, PA

Nemours is hiring a Nurse Case Manager. The Nurse Case Manager (NCM)/Case Management RN is responsible for the coordination of care of individual patients in the Inpatient and Emergency Department acute care environment. Through the use of the nursing process, patient care will be assessed, planned, implemented and evaluated with consideration to the appropriate use of resources, anticipatory discharge and timely progression of care. The NCM will manage care with a focus on designated clinical, operational, and financial outcomes for aggregate patient populations. In collaboration with the interdisciplinary team and a family-centered process, the NCM will work to improve outcomes as measured by timely discharge from acute inpatient care, connection to post-discharge care/appointments, family/caregiver access to needed supplies, reduced readmission rates, and improved patient/family satisfaction. Discharge planning, transitions of care and outpatient care of patients within the continuum of care will be aligned with:

• American Case Management Association Standards of Practice and Scope of Services (ACMA)
• American Case Management Association Transitions of Care (ACMA)
• Case Management Society of America Standards of Practice (CMSA)

The NCM is accountable for adherence to policies and procedures of Nemours Children's Hospital, Delaware, and other affiliated hospitals to which Nemours-delegated patients are admitted/seek care.

The NCM is expected to maintain all state and federal clearances for DE.

Qualifications:

• Diploma/AD required; BSN preferred
• Active Registered Nurse license in the applicable state(s) (required)
• Case management or utilization management certification (preferred)
• Minimum of five (5) years of progressive clinical experience, including utilization management, case management, or related healthcare operations

Primary Responsibilities:

1. Assesses inpatient and Emergency Department patients for discharge planning needs, social drivers of health, gaps in care, and access to post-acute services and supplies (e.g., DME, home nursing).
2. Collaborates with providers, social work, and the interdisciplinary team to develop and implement patient-centered plans of care and discharge plans, with a clear timeline and estimated discharge date.
3. Monitors clinical progression and barriers to discharge; escalates issues to support appropriate level of care, length of stay, and resource utilization.
4. Partners with Utilization Management to support medical necessity and correct patient status (inpatient vs. observation/OPER); supports denial prevention and appeals through timely, complete clinical documentation, educating providers around medical necessity/denials, and support for peer to peer reviews.
5. Identifies patients at risk for unsafe transitions, high ED utilization, or readmission; completes transition assessments and coordinates follow-up care and appointments.
6. Communicates with patients/families and the care team to address barriers, coordinate services, and adapt plans based on changes in clinical status or goals of care.
7. Provides patient/family education on the discharge process, including follow-up needs, and medications/supplies; confirms understanding and documents education as appropriate.
8. Initiates and coordinates referrals to internal and community resources to support discharge needs (e.g., home health, DME, transportation, pharmacy). Ensure timely and accurate delivery and fulfillment of discharge resources.
9. Coordinates transitions of care with outside hospital/facility case management and care coordination teams, including discharge to home, transfer to another acute care facility, home services, or skilled nursing facility

Nemours Children's Health is an internationally recognized pediatric health system serving more than 1.7 million patient encounters each year. We deliver care across six states through two freestanding children's hospitals — Nemours Children's Hospital, Delaware and Nemours Children's Hospital, Florida — along with a network of more than 80 primary, urgent, and specialty care practices and more than 40 hospital partnerships.

Backed by the Nemours Foundation and Alfred I. duPont Trust, our $1.7B nonprofit system is dedicated to improving children's health through clinical care, research, education, advocacy, and prevention. Our Whole Child Health approach focuses equally on prevention and treatment, partnering with communities to help every child thrive.

Inclusion and belonging guide our strategy and growth. We are committed to culturally relevant care, reducing health disparities, and fostering an environment where every associate, patient, and family feels supported and valued.

Learn more at Nemours.org.

• Job Identification 19287
• Job Category Registered Nurse
• Degree Level Associate Degree
• Job Schedule Full time
• Locations 1600 Rockland Road, Wilmington, DE, 19803, US (On-site)