Utilization Management (UM) Review Nurse (On-site)

Nexus Enterprises LLC • Schertz, TX

79d

About The Position

The Utilization Management (UM) 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.

Requirements

• 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, InterQual)
• 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

Nice To Haves

• Prior experience in utilization review, case management, or medical-legal review preferred

Responsibilities

• 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, InterQual, 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, and 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

Benefits

• Equal Employment Opportunities (EEO) to all Team Members and applicants for employment
• Commitment to creating an inclusive environment for all Team Members and applicants
• Encouragement for veterans to apply

What This Job Offers

• Career Level: Mid Level
• Education Level: No Education Listed