Utilization Review Nurse

RN Clinical Review Nurse (Utilization Review Nurse)

The Clinical Review Clinician for Appeals is responsible for performing clinical reviews to resolve and process appeals by examining medical records and clinical data. This role ensures that medical necessity for services is determined in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Responsibilities:

• Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing the basis for the appeal.
• Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards.
• Communicate with members, providers, facilities, and other departments regarding appeal requests.
• Generate appropriate appeals resolution communication and reporting for members and providers in accordance with company policies, State, Federal, and NCQA standards.
• Work with leadership to increase the consistency, efficiency, and appropriateness of responses to all appeal requests.
• Partner with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Perform other duties as assigned.
• Comply with all policies and standards.

Essential Skills:

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
• 2-4 years of related experience.
• Knowledge of NCQA, Medicare, and Medicaid regulations.
• Knowledge of utilization management processes.

Work Environment:

The role involves collaboration with a team of over 30 clinicians in the Medicare Appeals team. You will complete clinical reviews for preservice authorization denials and retrospective claim denials to determine medical necessity. The position supports continuity of service during a department BPO launch and recent staff turnover. You will complete clinical reviews for assigned cases through a round-robin distribution, update and process authorizations using InterQual, and communicate with MD reviewers, supervisors, and coordinators on determinations. Communication via Teams is used for quick questions and workflow alignment.

Job Type & Location:

This is a Contract position based out of Houston, TX.

Pay and Benefits:

The pay range for this position is $30.00 - $40.00/hr. Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type:

This is a fully remote position.

Application Deadline:

This position is anticipated to close on Aug 31, 2026.