Utilization Management Clinical Registered Nurse

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

📋 Description

• Facilitate precertification for inpatient admissions and outpatient procedures and services that require authorization.

• Conduct telephonic and/or concurrent reviews of inpatient admissions and extended outpatient treatment courses.

• Evaluate each request and pinpoint the relevant guidelines and regulatory standards.

• Utilize clinical decision-making skills to evaluate clinical acuity and the appropriateness of treatments and services.

• Prepare case summary evaluations for requests that do not meet medical necessity criteria.

• Collaborate with the medical director or their designee for review and resolution of cases.

• Ensure that denial letters are dispatched within the required regulatory timeframes.

• Develop provider communications that align with accrediting and regulatory standards, including clinical content and readability criteria.

• Inform providers in writing about the rationale behind decision-making.

• Work in conjunction with health plan disciplines and hold regular meetings with contracting and provider relations teams.

• Screen, identify, and refer potential members for case management and program or coverage evaluations.

• Recognize and report potential quality-of-care issues and instances of fraud and abuse to the appropriate department.

⛳️ Requirements

• A diploma in nursing is required, or an associate degree in nursing, or an associate degree in a related field recognized by the Texas Board of Nursing for obtaining and maintaining an RN license.

• An RN license issued by the Texas Board of Nursing or Nursing Licensure Compact is required.

• A minimum of 3 years of nursing experience is required.

• Successful candidates must complete respiratory fit testing.

• A bachelor's degree in nursing is preferred.

🏝️ Benefits

• Equal opportunity employer.

• A workplace that embodies HEART values, ensuring teammates feel valued, supported, and empowered.

• Respiratory fit testing in accordance with occupational health and safety standards.