Utilization Review Rn Jobs in Pittsburgh, PA (NOW HIRING)

Company :

Allegheny Health Network

Job Description :

Date Posted: 20260717

Location: Allegheny General Hospital

Department: Case Management, Emergency

Status: Full Time

Shift: 80 hours every two weeks

Rotating shifts, 40 hours per week, includes day/evening/overnights, rotating weekends and holidays

Union: Yes

CASE MANAGEMENT:

The Case Management Department at Allegheny General Hospital assists patients and their support systems in managing medical conditions effectively. Our team of talented Case Managers aims to individualize health care to meet each patient's specific needs with a patient-centric and outcome-driven focus.

ALLEGHENY GENERAL HOSPITAL:

Allegheny General Hospital (AGH), located on the North Side of Pittsburgh, is a 550+ bed hospital renowned for its advanced care across nearly every medical and surgical specialty. AGH is proud to hold Magnet recognition for nursing excellence and was the first accredited Level 1 Trauma Center in western Pennsylvania, providing 24/7 care for all types of traumatic injuries.

ALLEGHENY HEALTH NETWORK:

At AHN, employees trust working together and place patients at the center of all they do. This multi-hospital system, a part of Highmark Health, is transforming the future of healthcare by providing highly effective services to customers, patients and communities. AHN has commitment and dedication to being inclusive, valuing fresh perspectives, and offering the best growth and educational opportunities to employees.

GENERAL OVERVIEW

The Case Manager is a professional registered nurse with responsibility for creating, implementing, and evaluating care plans for patients and their families/caregivers across the health continuum. Incumbents will utilize nationally recognized standards of practice for case management by collaborating with providers, clinical teams, health plans, and external partners while advocating for patients and caregivers in order to align goals and plans. Case Managers serve as professional role models, utilizing their expertise in care management to promote a collaborative professional environment that optimizes outcomes, engages patients/caregivers in their healthcare, and supports effective resource utilization. Case Managers serve as key team members in the management of readmissions, length of stay, ED utilization, and patient/family satisfaction.

ESSENTIAL RESPONSIBILITIES

• Coordinates the clinical care with the patient, family, provider(s), and members of the interdisciplinary team.

• Contributes to or completes comprehensive assessment of patients and their families/caregivers, inclusive of clinical/physical needs, social determinants of health, and economic barriers impacting their ability to manage their health.

• Effectively identifies barriers and analyzes situations for assigned patient population, including risk for admission/readmission, external resources, and patient/family capacity in order to determine safe plans for transition and care coordination.

• Advocates for patients and families through effectively communicating with providers, interdisciplinary team members, payers, and post-acute partners to assure effective outcomes and care.

• Leverage understanding of industry standards to provide applicable education to patients, families, providers, and interdisciplinary team partners including but not limited to: appropriateness of care, documentation requirements, utilization review principles and criteria, insurance benefits and limitations, transition planning requirements, length of stay, and resource utilization.

• Actively seeks professional development opportunities through professional certification, mentoring/precepting, and/or participation on department/hospital/system committees.

• Adheres to the policies, procedures, rules, regulations, and requirements of hospitals and other clinical settings.

QUALIFICATIONS

Minimum

• Bachelor’s Degree in Nursing -OR- Bachelor’s Degree and Nursing Diploma -OR- 6 years of relevant experience in lieu of a degree.

• 3 years in a clinical nursing role

• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).

• Nationally recognized Case Management Certification within 5 years of start date.

• Critical thinking and problem solving

• Flexibility and adaptability to change

• Strong communication and collaboration skills with ability to tailor style according to target audience (providers, peers, clinical team members, patients, families)

• CPR certification

• Act 34 Criminal Background Clearance Certificate

• Act 33 Child Abuse Clearance Certificate

• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate

Additional Employment Requirements:

• CPR – American Heart Association

• Act 34 Criminal Background Clearance Certificate

• Act 33 Child Abuse Clearance Certificate

• Act 73 FBI Fingerprinting Criminal Background Clearance Certificate

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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Req ID: J284682