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Utilization Review Np Jobs in Delaware (NOW HIRING)

Christiana Care Health Services

Job Details Senior Nursing Students, Nurse Graduates and new RN's, it is time to apply for our ... Application Review * Your application will be forwarded to the leadership team of your highest ...

Bayhealth

Nurse Practitioner, Medical

Dover, DE · On-site

The Nurse Practitioner works within a collaborative model to provide quality care and to improve ... cases, reviewing full work-related incident and prescribing appropriate plan of care. Documents ...

ChristianaCare

Trauma Team, NP/PA

Newark, DE · On-site

$121K - $150K/yr

Both the surgical management and medical management can be accomplished through utilization of ... Acute Care NP license required Experience in the acute care setting preferred. ACLS required Annual ...

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Utilization Review Np information

What does a utilization review nurse practitioner do?

A Utilization Review Nurse Practitioner (NP) evaluates the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They review patient records, treatment plans, and insurance coverage to ensure that care meets established guidelines and regulatory requirements. Utilization Review NPs help coordinate care, prevent unnecessary procedures, and support cost-effective healthcare delivery while ensuring patient safety and quality outcomes.

What are some common challenges utilization review nurse practitioners face when collaborating with healthcare providers and insurance companies?

Utilization Review Nurse Practitioners often navigate the challenge of balancing patient advocacy with payer requirements. They must effectively communicate clinical justifications to both healthcare providers and insurance representatives, sometimes mediating disagreements over the necessity of certain treatments or hospital stays. Staying up-to-date with ever-changing insurance guidelines and ensuring timely documentation can also be demanding, but strong organizational and interpersonal skills help facilitate smooth collaboration and successful patient outcomes.

What are the key skills and qualifications needed to thrive as a utilization review nurse practitioner, and why are they important?

To thrive as a Utilization Review Nurse Practitioner (NP), you need expert clinical judgment, a strong understanding of healthcare regulations, and advanced assessment skills, typically supported by an active NP license and clinical experience. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of insurance guidelines such as Medicare and Medicaid are commonly required. Excellent communication, attention to detail, and critical thinking are vital soft skills for effective case evaluations and collaboration with providers. These competencies ensure accurate, efficient reviews that support quality care, compliance, and cost-effective treatment decisions.

What is the difference between Utilization Review Np vs Utilization Review Nurse?

AspectUtilization Review NpUtilization Review Nurse
CredentialsMaster's degree in Nursing, Nurse Practitioner certification, state licensureRegistered Nurse (RN) license, possibly with certification in utilization review
Work EnvironmentHealthcare facilities, insurance companies, utilization review organizationsHospitals, insurance companies, outpatient clinics
Job ResponsibilitiesAssess medical necessity, authorize treatments, make clinical decisions, often with greater autonomyReview medical records, support authorization processes, follow established guidelines

Utilization Review NPs typically have advanced clinical training and greater decision-making authority compared to Utilization Review Nurses. Both roles focus on evaluating medical necessity, but NPs often perform more complex assessments and can make independent recommendations, whereas nurses support the review process under supervision or guidelines.

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What job categories do people searching Utilization Review Np jobs in Delaware look for?

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Cities in Delaware with the most Utilization Review Np job openings:

Utilization Review Np jobs near you
Infographic showing various Utilization Review Np job openings in Delaware as of August 2026, with employment types broken down into 1% As Needed, 80% Full Time, 15% Part Time, 3% Contract, and 1% Nights. Highlights an 87% Physical, 3% Hybrid, and 10% Remote job distribution.

RN Utilization Management - Day Shift

Christiana Care

Newark, DE • On-site

$85K - $137K/yr

Other

Medical, Retirement, PTO

This job post has expired today. Applications are no longer accepted.

ChristianaCare rating

7.8

Company rating: 7.8 out of 10

Based on 131 frontline employees who took The Breakroom Quiz

135th of 898 rated healthcare providers

Job description

Job Details
Registered Nurse (RN) - Utilization Management
FT Day Shift (Hrs.: 8a-4:30p) - On-site
Newark, DE
ChristianaCare Hospital in Newark, DE, is seeking a Utilization Management Nurse (RN) with experience with insurance providers such as Aetna and Cigna, along with a background in an acute care hospital. RN will work on-site at the Newark Hospital.
PRIMARY FUNCTION:
Responsible for ensuring the delivery of efficient and effective health care while evaluating the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provision of the applicable health benefits plan.
UTILIZATION MANAGEMENT
  • Performs admission and concurrent review to identify medical necessity, level of care, and appropriateness of setting using established criteria and clinical guidelines within 24 hours of admission.
  • Reviews the admission assessment and collaborates with primary nurse and other health care providers to ensure a multidisciplinary plan-of-care is in place to meet identified patient care needs and desired outcomes.
  • Manages observation level of care and works with the attending physician and/or clinical provider caring for the patient to ensure observation status does not exceed 48 hours.
  • Identifies system issues that serve as barriers to care. Participates in the development and implementation of strategies to remove barriers and facilitate performance improvement measures.
  • Monitors efficiencies in scheduling diagnostic procedures and coordination of treatments to facilitate the achievement of effective clinical, fiscal, quality, and patient satisfaction goals.
  • Reports information generated from the utilization management referral process for LOS data and physician profile database.
  • Collaborates with the unit medical director and/or physician advisor to facilitate achievement of clinical, quality, financial, and patient satisfaction goals.
  • Notifies physician when a patient does not meet criteria for acute care hospitalization and pursues documentation to justify continued stay within 24 hours.
  • Collaborates with the Physician Advisor to facilitate the achievement of clinical, quality, financial, and patient satisfaction goals.
  • Presents "Letters of Non-Coverage" (LON) to patients and/or families when the acute stay is no longer necessary (Third Party and/or Medicare).
  • Communicates and secures continued stay authorization with Managed Care Organizations.
  • Tracks all carve-outs and submits reason codes for data entry.
  • Serves as a resource to nursing and ancillary staff, providing education on utilization review processes as needed.
  • Trends potential barriers to patient advancement through the system intervene assertively and appropriately when necessary.
  • Provides On-call support for the Transfer Center to evaluate medical necessity and appropriateness when a request is obtained from an outside facility for patient transfer to ChristianaCare
  • Identifies the need for the patient to be evaluated by other members of the health care team and takes appropriate action to facilitate.
  • ED UM works closely with ED providers to review medical necessity and/or collaborate with ED CM for discharge planning, as appropriate.
  • Actively participates in department operational planning work groups.
Education & Experience Requirements:
  • DE RN licensure or compact state RN licensure.
  • Bachelor's degree in nursing Required.
  • Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting. critical care experience is required.
  • Minimum 3 years of Utilization Management experience required.
  • Denial management experience is required
  • Prior experience working with insurance providers is preferred.
  • Completes a minimum of 8 continuing education credits (CEU'S) per year in Utilization and/or Case Management.

PHYSICAL DEMANDS:
Ability to ambulate within the hospital setting (walking, stairs, etc.). Occasional sitting, standing, and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs. Ability to sit or stand at a computer workstation and proficiently utilize computer equipment/programs for long periods of time.
WORKING CONDITIONS:
Occasional exposure to Office materials (i.e., White Out, Toner, etc.)
Annual Compensation Range $85,862.40 - $137,384.00
This pay rate/range represents ChristianaCare's good faith and reasonable estimate of compensation at the time of posting. The actual salary within this range offered to a successful candidate will depend on individual factors including without limitation skills, relevant experience, and qualifications as they relate to specific job requirements.
Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.
Post End Date
Aug 31, 2026
EEO Posting Statement
ChristianaCare offers a competitive suite of employee benefits to maximize the wellness of you and your family, including health insurance, paid time off, retirement, an employee assistance program. To learn more about our benefits for eligible positions visit https://careers.christianacare.org/benefits-compensation/

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About ChristianaCare

Sourced by ZipRecruiter

ChristianaCare is one of the country's most dynamic health care organizations, centered on improving health outcomes, making high-quality care more accessible and lowering health care costs. ChristianaCare includes an extensive network of outpatient services, home health care, urgent care centers, three hospitals (1,299 beds), a free-standing emergency department, a Level I trauma center and a Level III neonatal intensive care unit, a comprehensive stroke center and regional centers of excellence in heart and vascular care, cancer care and women's health. It also includes the pioneering Gene Editing Institute and was rated by IDG Computerworld as one of the nation's Best Places to Work in IT. ChristianaCare is a nonprofit teaching health system with more than 260 residents and fellows. It is continually ranked by U.S. News & World Report as a Best Hospital. With the unique CareVio data-powered care coordination service and a focus on population health and value-based care, ChristianaCare is shaping the future of health care.

Industry

Outpatient health care

Company size

10,000+ Employees

Headquarters location

Wilmington, DE, US

Year founded

1888

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