Texas Licensed Utilization Review Nurse
Job Summary
Providing comprehensive care coordination services, the full-time Texas Licensed Utilization Review Nurse will manage clinical reviews, conduct prior authorization and retrospective reviews, and ensure quality outcomes for members while working remotely with rotating weekend hours required.
Key responsibilities
- Prepares clinical reviews based on guidelines and presents recommendations to physician reviewers for final determination
- Conducts prior authorization and concurrent reviews focusing on utilization management and care coordination
- Monitors clinical quality concerns, escalates issues, and interacts with external providers to support the medical necessity review process
Required qualifications
- Current, unrestricted Texas nursing license or Compact License
- Diploma from an accredited school/college of nursing
- 1-2 years of experience in utilization management at a health plan
- 3-5 years of clinical experience in a hospital or ambulatory setting
- Knowledge of medical and insurance terminology, including CPT/ICD10 codes
Complete Job Description
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