Job Description

We are seeking a Utilization Review Nurse to join one of Houston’s largest Independent Physician Associations. This position is full-time and 100% on-site for the first three months. After that, the role transitions to a hybrid schedule with three days in the office (Monday through Wednesday) and two days working remotely (Thursday and Friday). Therefore, the Utilization Review Nurse must live in the Houston area.

The Utilization Review Nurse is responsible for ensuring quality, cost-effective healthcare services for members with varying levels of medical and/or behavioral needs. Working independently within the scope of RN or LVN licensure, this role coordinates prior authorization requests (medical and pharmacy), performs admission and outpatient reviews, and identifies cases requiring case management. The Utilization Review Nurse will collaborate with provider organizations using nationally recognized care criteria to determine appropriate levels of care and monitor resource utilization.

Resumes may be submitted directly or via email to [email protected].

Responsibilities:

• Use nationally accepted criteria (e.g., Milliman Guidelines, InterQual) to determine appropriate levels of care and monitor resource utilization practices.
• Coordinate and manage prior authorization requests, including preadmission, concurrent, and retrospective reviews.
• Evaluate treatment plans for medical necessity, cost-effectiveness, and appropriateness.
• Maintain active caseloads, providing interventions within the limits of expertise and licensure.
• Perform concurrent reviews to validate necessity for admissions and continued inpatient stays.
• Conduct retrospective reviews based on established guidelines and assist with discharge planning for hospitalized members.
• Provide consultation and referrals to case management personnel when appropriate.
• Collect clinical data and enter information into databases for documentation and reporting.
• Monitor key metrics, prepare reports on variances, and recommend health resources or interventions to enhance care quality.
• Uphold ethical conduct regarding patient confidentiality and professional practice.
• Collaborate with other UM Nurses, Case Managers, Medical Director, Transition of Care teams and Admin staff
• Attend meetings, participate in ongoing professional development, and complete all documentation within specified deadlines.

Requirements:

• Current RN or LVN license in the State of Texas (active and in good standing).
• Must have 2+ years of Utilization Management experience with a physician network or health plan.
• Preferred knowledge of case management principles and preparing denial letters.
• Proven ability to multitask effectively in a high-volume environment.
• Experience with Milliman Guidelines (MCG), InterQual, Standard National Care Guidelines, or equivalent.
• Commitment to quality and accuracy, with the capability to complete work efficiently and meet productivity standards.
• Must have flexibility to adjust schedule occasionally to accommodate deadlines or projects.

Benefits:

  This position offers a competitive benefits package which includes:

• Group benefits include medical, dental, vision, company paid $25k life with the option to add more voluntary life insurance coverage for employees and their family, STD, company paid LTD, 401k matching, and a variety of supplemental coverages such as hospital, cancer, legal, etc. available to the employee and their family.
• Employee funded FSA program.
• 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

About ROI Search Group:

ROI Search Group is a woman-led staffing firm based in Fishers, IN. We provide comprehensive staffing solutions including direct hire, contract, and contract-to-hire in addition to other specialized and executive searches. Our unique methodology enables us to attract top talent and support candidates' career progression, aligning with our clients' and candidates' priorities to create mutual success.

At ROI Search Group, we are committed to fostering a workplace that values and celebrates diversity. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or veteran status. We embrace the principles of equal employment opportunity and encourage all qualified candidates to explore career opportunities with us. We believe that a diverse and inclusive workforce enhances our creativity, innovation, and overall success. Join us in our commitment to equality and opportunity.

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