Utilization Management Review Nurse

The Utilization Management Review Nurse (UMRN) performs technical and administrative work required to evaluate the necessity, appropriateness, and efficiency of the utilization of medical services, procedures, and facilities. The UMRN supports the health system by applying clinical knowledge and industry-standard guidelines to ensure that care is provided at the appropriate level of care based on medical necessity. The UMRN promotes quality care and cost-effective outcomes, partnering with Care Management, Physician Advisors, Finance, and third‑party payers to deliver the best holistic outcomes for all patients. This position works with payers to reconcile denials and reconsiderations, assists with appeals as needed, and arranges peer‑to‑peer level reviews while collecting, analyzing, and addressing variances from the plan of care or care path with the physician and other members of the healthcare team. The UMRN participates in quality improvement activities, exemplifies professionalism, and promotes a customer‑friendly environment by utilizing ServiceFIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians. Minimum Qualifications Bachelor’s degree in Nursing from an accredited program. Licenses & Certifications Registered Nurse: Licensed to practice nursing in the State of Texas. Case Management Certification (ACM or CCM) within two years of hire. Basic Life Support: American Heart Association (AHA) or Red Cross approved program. Work Experience 5 years of experience in acute healthcare settings, including at least 2 years in Case Management, Quality Management, Utilization Management, or Coding. Communication Skills Above Average Verbal Communication (Heavy Public Contact) Exceptional Verbal (Public Speaking) Writing/Correspondence Writing/Reports Language Bilingual skills (preferred). Proficiencies Microsoft Word PC (personal computer) Microsoft Excel Microsoft PowerPoint Knowledge / Skills / Abilities Analytical Mathematics Medical Terms Utilization review tools: MCG and/or Change Healthcare (InterQual) Work Schedule Flexible: 8‑hour shifts as per system need, variable to 10‑12 as needed. Weekends: Depends on system needs. Telecommute available. Holidays: Depends on system needs. Other Special Requirements Equipment operated: Standard office equipment, computer software, etc. #J-18808-Ljbffr