Utilization Review Nurse

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

📋 Description

• Analyze clinical information to assess the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and levels of care.

• Review healthcare services and facilities according to relevant health benefit plans to ensure quality and cost-efficient patient care.

• Collaborate with intake staff, physicians, specialists, case managers, and other members of the care team.

• Facilitate timely and effective care authorizations, transitions, and utilization decisions.

• Conduct utilization and concurrent reviews of inpatient cases utilizing Milliman, Aetna, and BCBS criteria.

• Perform medical necessity reviews for services that require prior authorization.

• Request and assess clinical information necessary for reviewing requested services.

• Engage in discussions regarding cases and determinations with healthcare professionals and physician reviewers.

• Identify cases that necessitate intervention and collaborate with Case Managers.

• Ensure accurate documentation and adherence to audit standards.

• Participate in team meetings, educational sessions, and related activities.

• Review medical claims and pre-determinations for medical necessity and appropriateness.

• Identify opportunities for process improvements and enhance communication among departments.

• Consult with Physician Reviewers on complex or challenging cases.

⛳️ Requirements

• Current, unrestricted RN license (State license required).

• A minimum of 3 years of clinical nursing experience.

• At least 1 year of experience in Utilization Management (UM) or Utilization Review (UR).

• Strong analytical, critical thinking, and problem-solving abilities.

• Proficiency in Microsoft Office Suite (Excel, Word, Outlook).

• Familiarity with utilization management systems.

• Excellent verbal and written communication skills.

• Ability to interact effectively with both internal and external stakeholders.

• Strong organizational and time management skills.

• Capacity to manage multiple priorities independently.

• Comfort with appearing on camera for virtual meetings (e.g., Microsoft Teams).

• Preferred: Experience with Milliman or Aetna criteria.

• Preferred: Background in healthcare administration, medical necessity determination, or benefits management.

• Preferred: Experience in data interpretation and medical trend analysis.

🏝️ Benefits

• Excellent medical, dental, and vision insurance.

• Biannual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible.

• Basic Life and AD&D insurance provided by the company.

• Company-paid Short-Term and Long-Term Disability insurance.

• Flexible Spending Accounts available.

• 401(k) Retirement Plan with an employer match of up to 6%.

• Fully vested after 3 years of service.

• More than 10 paid holidays.

• Fully paid half-day Summer Fridays.

• Generous paid vacation and sick leave.

• Annual Paid Volunteer Day.

• Annual Tuition Reimbursement program.

• Annual Health and Wellness Reimbursement.

• Company-sponsored events.