Careers


Reports to: Chief Nursing Officer

Salary: TBD based upon Experience

Status: Full-Time / Permanent / Exempt/ Part- Time Remote

Location: Houston, TX

Position Summary:

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.

Responsibilities:

  • 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

Qualifications:

  • 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

Company Benefits:

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

Experience:

  • Utilization Management: 1 year (Required)
  • physician network or health plan: 1 year (Required)
  • Milliman Guidelines (MCG) or Intequal: 1 year (Required)

Location:

  • Houston, TX (Required)

License:

  • RN or LVN license in Texas (Required)

Language:

  • Spanish (Preferred)

Work authorization:

  • United States (Required)
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