Utilization Management RN - Remote In TX

TEKsystems•Austin, TX

17h•$39 - $47•Remote

About The Position

The Utilization Management RN works collaboratively with the Utilization Management team to ensure members receive the right care, at the right time, in the right setting. This role is responsible for prior authorizations, inpatient and outpatient medical necessity reviews, and concurrent, prospective, and retrospective utilization reviews. The RN applies clinical judgment and established criteria to evaluate medical services, supports discharge planning, ensures regulatory compliance, and promotes quality, cost-effective outcomes. In addition, this role mentors and trains new team members and serves as a clinical resource within the department.

Responsibilities

Perform prior authorization, concurrent, prospective, and retrospective utilization reviews for inpatient, outpatient, ambulatory, ancillary, and facility-based services.
Conduct telephonic reviews of inpatient hospital admissions and continued stays across acute, skilled, and long-term care settings.
Apply national standardized medical criteria, internal medical policies, and state and federal regulations to determine medical necessity.
Identify appropriate benefits, eligibility, and expected length of stay for requested services and procedures.
Manage utilization for acutely and chronically ill members to support optimal clinical and cost-effective outcomes.
Review and process all levels of appeal requests requiring clinical review.
Collaborate with facility and provider case managers to support safe and timely discharge planning.
Obtain and evaluate clinical documentation necessary to assess member condition and ongoing care needs.
Coordinate transitions between levels of care to ensure continuity and appropriateness of services.
Act as a member and family advocate by facilitating access to medically necessary care within benefit plans.
Consult with Medical Directors on cases requiring physician review or those not meeting clinical criteria.
Maintain effective communication with care management, disease management, and other internal teams.
Support accreditation, quality, and performance improvement initiatives (HEDIS, NCQA, URAC, QIA).
Monitor productivity and quality benchmarks and contribute to departmental performance goals.
Mentor and train new Utilization Management team members.
Attend staff meetings and complete assigned projects and work objectives on time.
Perform other related duties as assigned while maintaining professional conduct at all times.