Utilization Review Nurse Case Manager

TX Assoc of School Boa • Austin, TX

15h • Hybrid

About The Position

As a Utilization Review Nurse Case Manager, you combine strong clinical judgment with a working knowledge of workers’ compensation requirements to help ensure claimants receive the right care at the right time and in the right setting. You’re skilled at evaluating requested services for medical necessity and appropriateness using ODG guidelines and communicating with providers to obtain timely, complete clinical documentation. You bring a collaborative, solutions-oriented approach to complex cases, partnering with internal teams to support safe, effective treatment while maintaining compliance with regulatory and payer requirements.

Requirements

• Current vocational nurse (LVN) or registered nurse (RN) license to practice in the State of Texas.
• Minimum two years of clinical nursing experience; workers’ compensation utilization review experience preferred.
• Ability to evaluate requested treatment using ODG guidelines, accepted standards of practice, and written criteria to support objective, defensible determinations.
• Strong documentation skills, including timely, accurate entry in a complex claims/risk management software system and other applications.
• Comfort participating in claims review activities, including audit support and fee negotiation for workers’ compensation cases (as assigned).
• Commitment to maintaining licensure and staying current with accepted practices through continuing education and professional utilization/case management resources.

Responsibilities

• Evaluate requested treatment for workers’ compensation claimants using ODG guidelines, accepted standards of practice, and written criteria to support safe, appropriate care.
• Coordinate referrals to physician advisors, communicate with providers, peer review physicians, and adjusters, and document decisions accurately in the claims/risk management system while safeguarding PII.
• Participate in clinical discussions, team meetings, and department or company meetings and events as part of a collaborative Utilization Review team.
• Complete utilization review and preauthorization requests for workers’ compensation claims, using ODG and clinical standards and documenting determinations clearly and consistently.
• Partner with claims adjusters and internal teams to answer medical questions, flag files appropriate for external case management referrals, and help coordinate appropriate care.
• Coordinate physician advisor reviews and peer review interactions, communicating with provider offices to obtain clinicals and keep determinations within required timeframes.
• Participate in claims review activities, including audit support and fee negotiation for workers’ compensation cases, as assigned, with an eye toward appropriate, cost-effective care.
• Preserve confidentiality and properly handle protected information and PII in accordance with applicable laws, regulations, and organizational requirements.
• Accurately and timely enter review information, determinations, and communications in the claims/risk management system and related applications.
• Provide input to update clinical criteria and stay current on accepted practices through continuing education and professional utilization/case management resources.
• Serve as the contact nurse on assigned internal nurse case management files that are medically complex, coordinating next steps with claims and clinical stakeholders.

Benefits

• competitive pay
• rich benefits (including retirement matching of 2:1 up to 5% after one year, which means that if you contribute 5% to the plan, TASB will contribute 10%)
• family-friendly paid leave
• onsite daycare
• onsite gym
• wellness program
• tuition reimbursement
• hybrid work options

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 251-500 employees