Registered Nurse, Utilization Review
MMC Group•Austin, TX
•Remote
About The Position
This is a remote Registered Nurse, Utilization Review position for candidates living in the Austin, TX area. It is a long-term opportunity with a high potential for extension. The role allows you to use your clinical expertise to improve healthcare outcomes without providing direct patient care. You will evaluate medical necessity, ensuring members receive medically appropriate, high quality, and cost-effective healthcare services. You will collaborate with physicians, healthcare providers, and interdisciplinary teams.
Requirements
- Current Registered Nurse (RN) license in good standing
- Experience performing Utilization Review, Case Management, Care Management, or Medical Necessity reviews
- Knowledge of Medicaid programs and utilization management principles
- Experience applying medical necessity criteria
- Understanding of the Texas Administrative Code (TAC)
- Strong clinical assessment and critical thinking skills
- Excellent written and verbal communication abilities
- Strong organizational and time management skills
- Ability to work independently in a remote environment
- Microsoft Word
- Microsoft Excel
- Electronic documentation systems
- Ability to navigate multiple computer applications simultaneously
Nice To Haves
- Enjoy using clinical expertise to improve healthcare outcomes
- Have exceptional analytical and critical thinking skills
- Are detail oriented and able to make sound clinical decisions
- Communicate professionally with providers and interdisciplinary teams
- Can manage multiple priorities in a fast-paced environment
- Work independently while remaining engaged with a collaborative remote team
Responsibilities
- Conduct pre-service, concurrent, and retrospective utilization reviews
- Evaluate medical necessity for outpatient services and out-of-network care
- Assess the appropriateness of treatment settings using evidence-based clinical guidelines
- Collaborate with physicians, healthcare providers, and interdisciplinary teams
- Promote high-quality, cost-effective healthcare outcomes
- Optimize member benefits while ensuring compliance with Medicaid requirements
- Apply Texas Administrative Code (TAC) guidelines and medical necessity criteria
- Document review decisions accurately and thoroughly
- Maintain productivity, quality, and compliance standards
- Participate in team meetings, training, and continuous improvement initiatives
Benefits
- Medical
- dental
- vision coverage
- Life and disability insurance
- Additional voluntary benefits
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
