Utilization Review Nurse; On-site

Full-time

The Utilization Review Nurse is responsible for analyzing medical records for medical-legal reviews and producing high-quality, professional executive summaries. These reports must follow client-specific and evidence-based guidelines, incorporating clear rationales for determining medical necessity. The role involves prospective, concurrent, and retrospective review of inpatient and outpatient treatment, certifying medical necessity, and recommending appropriate lengths of stay. Reports must be thorough, accurate, and tailored to the specific requirements of each case and client.

• Analyze and interpret clinical documentation for medical-legal reviews
• Evaluate patient records to determine medical necessity and appropriateness of care using pre-approved guidelines (e.g., ODG, MTUS, Inter Qual, MCG)
• Draft clear, concise, and professional executive summaries that:
  • Outline patient demographics and clinical course
  • Summarize and assess treatment plans and physician orders
  • Apply relevant evidence-based criteria
  • Provide clear rationale and recommendations
• Ensure all reports are grammatically correct, free of spelling errors, and professionally formatted
• Dictate and finalize report content using designated systems
• Collaborate with physicians and clinical staff to clarify documentation or resolve discrepancies
• Amend reports as new clinical information becomes available
• Perform moderate research on a case-by-case basis to support findings
• Participate in interdisciplinary teams to support high-quality patient care outcomes
• Maintain a consistent caseload of 20 cases per day post‑training
• Achieve and maintain a Quality Assurance (QA) score of 97% or higher
• Demonstrate consistent, reliable attendance and meet established deadlines
• Perform additional duties as assigned

• In-depth understanding of anatomy, medical/surgical modalities, and imaging techniques
• Strong knowledge of utilization review processes and criteria application
• Excellent written communication skills, with a strong focus on grammar, spelling, clarity, and organization
• Proven ability to analyze complex clinical information and apply critical thinking
• Familiarity with medical necessity guidelines (ODG, MTUS, MCG, Inter Qual)
• Ability to read and interpret clinical reports, technical documentation, and regulations
• High proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
• Strong attention to detail and ability to meet high standards for accuracy
• Effective time management and multitasking skills in a deadline‑driven environment
• Strong customer service orientation with the ability to communicate professionally with clients and providers
• Ability to maintain confidentiality and demonstrate sound judgment
• Ability to type a minimum of 45 WPM
• Excellent verbal and written communication skills in English

• Active, unrestricted TX Registered Nurse (RN) license
• Minimum of 2–3 years of relevant clinical experience
• Prior experience in utilization review, case management,/, or medical‑legal review preferred

• Current TX RN licensure, without restrictions
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No

This position requires sitting, bending, and stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 10 lbs. Ability to learn technical material. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office productivity machinery such as a calculator, copy machine, printer, etc.

The person in this position frequently communicates with guests, team members, and vendors and must be able to exchange downside information.

The Company is a veteran‑owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national…