PRN Utilization Management Review Nurse

Job Summary

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. This role supports the health system by utilizing clinical knowledge, expertise and industry standard clinical guidelines, carrying the responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity.

The UMRN promotes quality care and cost‑effective outcomes to enhance the physical, psychosocial and vocational health of individuals, 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 review while collecting, analyzing and addressing variances from the plan of care/care path with physicians and other members of the healthcare team.

The UMRN participates in quality improvement activities, exemplifies professionalism, and promotes a customer‑friendly environment by utilizing Service

FIRST behaviors in interactions with Harris Health team members, payer vendors, and physicians.

Degrees: Graduated from an accredited school of Nursing with a Bachelor’s in Nursing.

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 from the American Heart Association (AHA) or a Red Cross approved program.

Work Experience: Five years of experience in acute health care settings, including at least two years in Case Management, Quality Management, Utilization Management, or Coding.

Communication

Skills:

Above average verbal communication with heavy public contact; exceptional verbal public speaking; writing and correspondence; writing and reporting.

Language: Bilingual skills preferred.

Proficiencies: Microsoft Word, PC, Microsoft Excel, Microsoft PowerPoint.

Knowledge, Skills & Abilities: Analytical; mathematics; medical terminology; utilization review tools including MCG and/or Change Healthcare (Interqual).

Flexible: Eight‑hour shifts as needed; shift length can vary up to ten to twelve hours.

Weekends: Variable based on system needs.

Telecommute: Available as needed.

Holidays: Variable based on system needs.

Equipment operated: standard office equipment and computer software.