Commercial Utilization Review Nurse (RN, LVN or LPN) at Prominence Health Reno, NV

Job Summary

The Utilization Review (UR) Nurse (initial clinical reviewer) is a registered nurse (RN) or health professional (licensed practical nurse (LPN) or licensed vocational nurse (LVN)), who possesses an active, current, unrestricted, and valid professional license or certification in each state or territory in the United States (U.S.) that the organization provides utilization management (UM) services, if the UR RN is reviewing clinical cases in that state.

• During the initial screening process, UR RN’s are available to non-clinical administrative staff while non-clinical administrative staff perform initial screening.
• UR RN reviews and evaluates clinical cases for appropriateness against established criteria and published medical evidence.
• The UR Nurse, using clinical and operational knowledge, assesses needs and coordinates resources within and outside the benefit plan to promote optimal health benefits and outcomes (both clinical and financial). Initial clinical reviewers have the appropriate clinical background to render decisions requiring clinical judgment and experience.
• The UR Nurse (initial clinical reviewer) may assist in the notification process for non-certifications, but does not issue non-certifications.
• The UR Nurse reviews requests for medical services and consults or refers to a Medical Director for clinical cases that require additional expertise.
• The UR Nurse measures and reviews performance outcomes, proposes and implements improvement processes and system enhancements to achieve desired results, identifies appropriate resources, demonstrates knowledge in managing each case, maintains accurate records, and provides timely verbal and written reports as directed.

• Graduation from an accredited nursing education program.
• Current, unrestricted, active, and valid license to practice in the State of Nevada, Florida, and/or Texas as a registered nurse.
• Practice as a health professional in a state or territory of the United States.
• Minimum of three years of Utilization Review/Case Management experience.
• Recent (within past 3 years) working knowledge of Interqual criteria and Milliman Care Guidelines.
• Minimum of three years in clinical medical/surgical nursing practice within a hospital setting.

• Ability to effectively communicate in English, both verbally and in writing.

• Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ) preferred.
• Attention to detail with ability to prioritize, problem solve and multi-task.
• Ability to quickly analyze and interpret data and write reports using standard medical terminology.
• Experience executing strategies and organizing and prioritizing multiple projects and relationships with key stakeholders and program implementers.
• Written and oral communication skills, including large and small group presentations, group facilitation and training.
• Ability to influence others and work collaboratively with key partners to achieve positive results.
• Ability to use relevant tools (e.g. word processing, spreadsheet, email and database programs and voicemail).
• Empathetic, Caring, Compassionate Listener.
• Excellent computer skills.
• Able to work with a diverse multicultural and socioeconomic population.
• Familiarity with health care delivery and/or health insurance programs.

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries! More information is available on our Benefits Guest Website:

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.