Job Description

Overview

We are looking to hire a Utilization Review Nurse for a Healthcare Organization in Houston, Texas, This is a full time permanent role. The position is hybrid but will start off full time onsite. Once training is completed, it will transition into a hybrid role. The candidate must have inpatient Utilization Review experience.

Job Summary

The Utilization Review Nurse plays a critical role in evaluating the appropriateness and necessity of patient care, ensuring compliance with regulations, and promoting cost-effective practices. This role involves critical analysis of medical records, collaboration with healthcare providers, and communication with insurance companies, all aimed to enhance patient outcomes while optimizing organizational efficiency.

Key Responsibilities

• Review Medical Records: Thoroughly evaluate patient medical records to assess the necessity and appropriateness of treatments and services.
• Conduct Audits: Regularly audit medical records and healthcare practices to ensure compliance with federal, state, and local regulations.
• Coordinate with Healthcare Providers: Collaborate with physicians, nurses, and other healthcare professionals to gather essential information and recommend optimal care pathways.
• Work with facilities to facilitate approvals and organize necessary peer reviews.
• Insurance Liaison: Communicate with insurance companies to effectively confirm coverage for recommended treatments and manage appeals or disputes.
• Patient Guidance: Educate patients and their families on treatment options, explaining benefits and risks to empower informed decision-making.
• Maintain Documentation: Keep accurate, detailed records of evaluations, recommendations, and all communications regarding patient care and compliance.
• Collaboration: Partner with clinical and administrative teams to promote compliance with healthcare standards and practices.
• Training and Education: Provide healthcare staff with education and training on compliance protocols and best practices in utilization review.
• Audit Documentation: Maintain comprehensive records of audits, investigations, and compliance activities to support transparency and accountability.
• Stay Informed: Keep abreast of changes in healthcare policies, clinical practices, and regulations to provide informed recommendations and maintain best practices.

Qualifications

• Registered Nurse (RN) licensure required.
• Detail-oriented with strong analytical skills.
• Ability to collaborate with healthcare providers and communicate effectively with insurance companies.
• Knowledge of federal, state, and local healthcare regulations.

Skills

• Excellent communication and coordination skills.
• Proficient in medical record review and audit processes.
• Strong ability to educate and train staff.
• Exceptional documentation skills.

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