Registered Nurse – Utilization Review

This is a fully remote position, open to applicants in Texas.

📋 Description

• Conduct thorough medical necessity screenings and submit cases for review by the Physician Advisor.

• Obtain and document service authorizations from payers.

• Oversee concurrent disputes effectively.

• Collaborate with payers, physicians, office personnel, and ancillary departments.

• Ensure timely, complete, and clear documentation within the Tenet Case Management documentation system.

• Keep patient demographic and insurance information accurate.

• Identify and document potentially avoidable days.

• Recognize and report both overutilization and underutilization.

• Facilitate resource coordination to promote optimal health, access to care, and appropriate resource use.

• Confirm that care is delivered at the appropriate level, based on medical necessity.

• Negotiate with payers on an individual case basis when necessary.

• Work with payers to authorize the correct level of care and medically necessary length of stay.

• Ensure compliance with regulatory requirements, accreditation standards, and Tenet policies.

• Provide education to payers, physicians, hospital and office staff, and ancillary departments regarding covered services and benefit administration.

⛳️ Requirements

• Must be a graduate of an accredited nursing program.

• Requires 2 years of experience in acute hospital or behavioral health patient care.

• A minimum of 1 year of utilization review experience in an acute hospital or in a commercial/managed care payer environment is required.

• Current RN license, certification, or registration as mandated by law or regulation in the state of practice.

• Active RN license for the relevant state(s).

• An academic degree in nursing (bachelor's or master's) is preferred.

• Accreditation as a Case Manager (ACM) is preferred.

🏝️ Benefits

• Medical, dental, vision, and life insurance.

• 401(k) retirement savings plan with employer matching.

• Generous paid time off.

• Opportunities for career development and continuing education.

• Health savings accounts available.

• Flexible spending accounts for healthcare and dependents.

• Employee Assistance program.

• Employee discount program.

• Pet insurance options.

• Legal insurance coverage.

• Accident and critical illness insurance.

• Long term care insurance.

• Benefits for elder and childcare.

• Auto and home insurance options.

• A supportive work environment that encourages professional growth and a healthy work-life balance.