Utilization Review Nurse, RN

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

📋 Description

• Deliver holistic care coordination services throughout the care continuum.

• Prepare clinical assessments utilizing established clinical guidelines and present recommendations to physician reviewers for final decisions.

• Execute prior authorization, concurrent, and retrospective utilization management evaluations.

• Assist in discharge planning, care coordination, clinical outcomes, and overall quality of care.

• Oversee clinical quality issues, identify outlier cases and prolonged length-of-stay situations, and escalate complex matters.

• Engage with external facilities and providers to collect clinical data for medical necessity assessments and care plans.

• Support coding, medical records/documentation, pre-certification, reimbursement processes, and manage claim denials/appeals.

• Employ active listening and motivational interviewing techniques during member interactions and document these communications.

• Evaluate and facilitate suitable clinical programs and discharge planning post-discharge.

• Handle departmental escalations to resolution and collaborate with the Medical Director on case management and utilization management cases.

• Take part in virtual team huddles, individual supervisory meetings, instant messaging, check-ins, and member/provider communications.

⛳️ Requirements

• Must possess a current, unrestricted Texas nursing license or a Compact License; please include license number(s) and corresponding state(s) in your resume.

• A diploma from an accredited nursing school/college is mandatory.

• 1-2 years of experience within a health plan performing utilization management with adherence to standard practice guidelines.

• 3-5 years of clinical experience in either a hospital or outpatient setting providing direct patient care.

• Prior experience in healthcare/managed care appeals is required.

• Proficient understanding of medical and insurance industry terminology, including basic CPT/ICD10 codes, authorization processes, digital health programs, and NCQA/URAC standards.

• Experience in reaching out to and educating members via telephone.

• Capability to work autonomously in a fast-paced, deadline-driven, tech-savvy work environment.

• Interest or experience in areas such as cardiology/pulmonology, women’s health, orthopedic surgery/physical medicine, primary care/pediatrics, or oncology is preferred.

• A dedicated, private workspace and secure handling of sensitive documents are required.

• Access to a high-speed internet connection/service is essential.

• Must reside within the United States, specifically in the CST or EST time zones.

• Availability for rotating on-call weekend duties related to utilization review cases.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance, alongside life and disability coverage.

• Retirement savings plan with a company match.

• Generous paid time off/vacation policy.

• Opportunities for professional development.

• Flexible and remote working environment.

• Competitive salary.