Utilization Review Nurse
On-sitePlano, Texas, United States
Job Summary
Perform initial and concurrent review activities to validate medical necessity and appropriateness of treatment plans using medically accepted criteria. Collect clinical and non-clinical data, verify eligibility, and determine benefit levels according to contract guidelines. Coordinate discharge care to assess efficiency, effectiveness, and quality of medical and surgical services while serving as a liaison between providers and network management divisions. Provide information regarding utilization management requirements and operational procedures to members, providers, and facilities. This 6-month remote assignment is based in Texas, specifically the Austin area (Travis/Williamson Counties) or Richardson area (Dallas/Collin Counties).
Required Qualifications
- Registered Nurse (RN) with a valid, current, unrestricted license in the state of operations
- 3 years of clinical experience in a Physician's office, Hospital/Surgical setting, or Health Care Insurance Company
- Knowledge of medical terminology and procedures
- Verbal and written communication skills
Desired Qualifications
- MCG or InterQual experience
- Utilization management experience
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