Remote Utilization REVIEW NURSE - RN
Houston, Harris County, Texas, 77001, USA
Listed on 2026-08-10
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Nursing
RN Nurse, Clinical Nurse Specialist, Nurse Practitioner, Healthcare Nursing
Remote Utilization Review Registered Nurse (UR RN)
Nexus Health Systems is seeking an experienced Utilization Review Registered Nurse (UR RN) to join our growing Utilization Management team. This fully remote position plays a critical role in ensuring patients receive medically necessary, high-quality care while promoting appropriate resource utilization and regulatory compliance.
If you're a detail-oriented RN with experience in utilization review, case management, or behavioral health and enjoy collaborating with interdisciplinary teams to improve patient outcomes, we'd love to hear from you.
What You'll Do- Conduct concurrent and retrospective utilization reviews to determine medical necessity and appropriate level of care.
- Apply evidence-based criteria, including Inter Qual (or similar), to support clinical decision-making and payer compliance.
- Collaborate with physicians, case managers, and interdisciplinary teams to facilitate timely authorizations, discharge planning, and appropriate transitions of care.
- Review clinical documentation to ensure accuracy, completeness, and compliance with payer and regulatory requirements.
- Manage insurance authorizations, denials, appeals, and level-of-care determinations.
- Monitor utilization trends and contribute to quality improvement initiatives that enhance patient outcomes and operational efficiency.
- Participate in multidisciplinary utilization review meetings and provide recommendations to optimize care delivery.
- Maintain accurate documentation within the electronic health record (EHR) while ensuring HIPAA compliance.
Required
- Associate Degree in Nursing (ADN) from an accredited nursing program.
- Current, unrestricted Texas RN license or Compact RN license.
- Minimum of 2 years of acute care clinical nursing experience.
- At least 3 years of Utilization Review or Case Management experience involving complex medical/surgical and/or behavioral health patients.
- Strong knowledge of payer guidelines, medical necessity criteria, and utilization management principles.
- Excellent critical thinking, communication, and organizational skills.
- Proficiency with electronic health records (EHRs) and Microsoft Office applications.
Preferred
- Bachelor of Science in Nursing (BSN).
- Experience with Inter Qual or MCG criteria.
- Behavioral health utilization review experience.
- Experience with Meditech.
- Professional certifications such as CCM, CPHQ, or HCQM.
At Nexus Health Systems, our mission is to improve lives through compassionate, high-quality care. As a member of our Utilization Review team, you'll collaborate with dedicated healthcare professionals while helping ensure patients receive the right care at the right time.
We offer:
- Competitive compensation
- Comprehensive medical, dental, and vision benefits
- Paid time off and company holidays
- 401(k) with company match
- Professional development and continuing education opportunities
- A collaborative, mission-driven culture
- Fully remote work environment
If you're ready to make a meaningful impact in healthcare while enjoying the flexibility of working remotely, we'd love to hear from you.
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