Utilization Review Nurse

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

📋 Description

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

• Execute medical necessity assessments for services requiring prior authorization, applying specific utilization criteria.

• Request and assess clinical information necessary for the evaluation of requested services.

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

• Identify cases that need intervention and collaborate with Case Managers as necessary.

• Maintain precise and accurate documentation to ensure compliance with audit standards.

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

• Review medical claims and pre-determinations to assess medical necessity and appropriateness.

• Spot opportunities for process enhancement and improve communication across departments.

• Consult with Physician Reviewers for complex or challenging cases.

⛳️ Requirements

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

• At least 3 years of clinical nursing experience.

• A minimum of 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) and knowledge of utilization management systems.

• Excellent verbal and written communication skills, capable of effectively interacting with internal and external stakeholders.

• Strong organizational and time management capabilities, with the ability to manage multiple priorities independently.

🏝️ Benefits

• Fantastic medical, dental, and vision insurance*

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

• Company-provided Basic Life and AD&D

• Company-paid Short-Term and Long-Term Disability**

• Flexible Spending Accounts*

• 401(k) Retirement Plan with up to a 6% employer match** (100% fully vested after 3 years)

• 10+ paid holidays

• Half-day Summer Fridays

• Generous paid vacation and sick time

• Annual paid Volunteer Day

• Annual Tuition reimbursement

• Annual Health and Wellness reimbursement

• Lots of fun company events