Reports to: Chief Nursing Officer
Salary: TBD based upon Experience
Status: Full-Time / Permanent / Exempt/ Part- Time Remote
Location: Houston, TX
The Utilization Review Nurse works independently to plan, implement, and/or coordinate quality patient care and cost-effective utilization of healthcare services. Utilization Review Nurse coordinates medical and/or pharmacy prior authorization request, perform preadmission, concurrent and retrospective review of inpatient admissions and outpatient services, identifies cases for case management.
- Applies nationally accepted criteria that include general rules and time definitions to determine appropriate levels of care and to illuminate resource utilization practices with provider organizations.
- Skill and proficiency in applying highly technical and critical thinking principles, concepts, and techniques that are central to the Nursing profession.
- Makes recommendations regarding health resources.
- Collect clinical data and enters information into database for documentation purposes.
- Evaluates member’s treatment plan for appropriateness, medical necessity and cost effectiveness.
- Maintains an active caseload providing interventions as needed within area of expertise and limits of credentials.
- Maintains a high level of ethical conduct regarding confidentiality, dual-relationships, and professional stature.
- Participate in continuing education activities, remaining knowledgeable in areas of expertise
- Attend meetings as appropriate and meet regularly with supervisor to exchange pertinent information and receive supervision
- Timely completion of documentation, follow-up, etc. within specified deadlines.
- Perform verification and pre-certification authorizations using approved guidelines, screening criteria and protocols and refers authorizations to the Medical Director that require additional expertise.
- Perform concurrent review to validate the medical necessity for admissions, determine the appropriate level of care and the necessity for continued inpatient stay.
- Monitor retrospective review requests based on established review guidelines.
- Assist with discharge planning for members who have been hospitalized.
- Provide appropriate consultation and referral to Case Management Personnel.
- Other duties as designed by Management.
- Partial Remote
- MUST maintain a current RN or LVN license in the State of Texas
- MUST HAVE prior experience with Utilization Management
- MUST have prior experience with a physician network or health plan
- MUST have Milliman Guidelines (MCG) experience Intequal, Standard National Care Guidelines or equivalent
- MUST have flexibility to adjust the schedule occasionally in order to accommodate other schedules and/or deadlines or projects
- Qualifying Internet capabilities
- Preferred knowledge in case management principles, utilization management procedures and practices
In a full-time permanent position, you will be able to participate in our company benefit program which includes:
- Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employee and their family, STD, company paid LTD, 401k, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
- Employer funded HSA and HRA programs.
- Paid Time Off ranging from 5-28 days depending on length of service.
- Profit Sharing Bonus Program
- 100% Employer Paid Pension Plan after 5 years
- Access to company gym and locker rooms in Houston offices.
Job Type: Full-time
- Utilization Management: 1 year (Required)
- physician network or health plan: 1 year (Required)
- Milliman Guidelines (MCG) or Intequal: 1 year (Required)
- RN or LVN license in Texas (Required)