RN Utilization Review / Medical Review

MMC Group • Austin, TX

8h • $41 • Remote

About The Position

We are seeking a Registered Nurse with utilization review or medical review experience to support pre-service, concurrent, and retrospective reviews in a remote environment. This role focuses on ensuring medically appropriate, high-quality, and cost-effective care by applying clinical judgment, regulatory guidelines, and medical necessity criteria. This position is ideal for an RN who is detail-oriented, highly analytical, and comfortable collaborating with healthcare providers in a non-clinical, administrative setting.

Requirements

• Active Registered Nurse (RN) license
• Experience conducting utilization review, medical review, or similar non-bedside nursing functions
• Ability to work assigned shifts between 7:00 AM and 7:00 PM, with a primary 10:00 AM-7:00 PM schedule
• Strong understanding of medical necessity criteria
• Working knowledge of Texas Administrative Code (TAC) regulations
• Proficiency with Microsoft Word and Excel
• Excellent clinical judgment, analytical thinking, and documentation skills
• Ability to work independently in a remote environment
• Strong communication skills for provider collaboration

Nice To Haves

• Local residency in or near Austin, TX preferred

Responsibilities

• Conduct pre-service, concurrent, and retrospective utilization reviews
• Assess medical necessity for outpatient services, out-of-network services, and appropriateness of treatment settings
• Collaborate with healthcare providers to promote quality member outcomes and optimize benefit utilization
• Ensure care decisions align with clinical guidelines, regulatory standards, and professional scope of practice
• Promote effective and efficient use of healthcare resources
• Apply Texas Administrative Code (TAC) rules as applicable
• Document review decisions clearly and accurately
• Support quality, compliance, and cost-containment objectives

Benefits

• MMC offers health insurance plans for our active candidates on assignment, including: Medical, dental, and vision coverage
• Life and disability insurance
• Additional voluntary benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed