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Clinical Operations Director (RN) Registered Nurse $60k-$75K Utilization Review M-F 8-5

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.


· 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.

· Provides telephonic case management, referral of resources, education and other clinically based activities to plan member.

· Provides medical management to plan members through communications with the members, the physician, other health care providers, the employer and the referral source.

· Makes recommendations regarding health resources.

· Collect clinical data and enters information into database for documentation purposes.

· Monitors and evaluates the member's response to health care needs.

· Evaluates member's treatment plan for appropriateness, medical necessity and cost effectiveness.

· Implements care such as negotiating the delivery of durable medical equipment, assist with discharge planning, when applicable, and assist with arranging equipment through \t designated vendors.

· Maintains an active caseload providing interventions as needed within area of expertise and limits of credentials.

· Acquires and provides detailed information regarding an assigned member to establish the foundation for treatment plan.

· Works with member using professional judgment and discretion to implement the team determined Team Plan.

· 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.

· Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.

· Conduct patient satisfaction surveys.

· Other duties as designed by Management.


· 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

· MUST have flexibility to adjust the schedule occasionally in order to accommodate other schedules and/or deadlines or projects

· 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

Clinical Operations Director (RN) Registered Nurse $60k-$75K Utilization Review M-F 8-5

Houston, TX
Full Time

Published on 03/31/2020