Utilization Review Coordinator Jobs in Decatur, TX

PreCert Nurse - LVN Utilization Review Nurse (Administrative Nursing)

Are you looking for a challenging and impactful nursing career that will diversify your nursing skills? Tired of working long hours and standing on your feet all day? Want to have work-life balance? If you enjoy working in a positive environment, Nexus has the solution for you with an exciting nurse administrative role! If this sounds like the kind of career move for you to make, we want to talk with you!

ABOUT THE COMPANY:

Nexus is dedicated to connecting quality healthcare professionals with the outcome needs of our partners in the health, insurance, and legal industries. The heart of our drive for quality and excellence rests in our unflinching integrity; we bend over backwards to provide the best possible service but will never bend our integrity. Nexus realizes that behind the paperwork and reports, there are people: mothers, fathers, sisters, brothers, sons, and daughters. These are people in need of the best, most accurate, medical care possible and we are tasked with ensuring they receive it in an efficient and cost-effective manner. We offer competitive compensation and fantastic benefits, as well as a collegial workplace in a casual dress environment. We encourage professional development and advancement as you learn our unique utilization management solutions.

WHAT WE LOOK FOR:

Our ideal candidate is a highly motivated and dynamic individual that thrives in a fast-paced research-oriented environment. Someone who is willing to learn and grow in a different sector of the nursing field.

WHAT WORKING AT NEXUS IS LIKE:

· Positive work environment, offering multiple work schedules and shift differential

· On-site fitness center, showers, nursing mothers’ rooms, snack bar, state of the art lounge, ergonomic workspace, and filtered water refill stations

· Exceptional benefits to include paid time off, health, dental, vision, disability, life insurance, holiday pay, parental leave, employee assistance and wellness programs and 401(k)

· Incentive programs for high quality performance

· Extensive training throughout the onboarding process

· Excellent opportunities for professional growth and development

POSITION OVERVIEW:

The primary function of the PreCert Nurse is to effectively review and analyze medical records of patients in need of care and create executive reports that are submitted to a physician for review. Each executive report includes a summary, appropriate criteria/guidelines, and a rationale.

What will be my duties and responsibilities?

· Perform a review of services for medical appropriateness utilizing pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment (e.g., ODG, MTUS, Milliman Care Guidelines, InterQual)

· Audit and analyze patient records to ensure quality patient care and necessity of services

· Provide clinical knowledge and act as a clinical resource to non-clinical staff

· Enter and maintain pertinent clinical information in various medical management systems

· Maintain knowledge of regulatory requirements (i.e., URAC), and state utilization review standards

· Use of clinical logic and reasoning to determine appropriate evidence-based guidelines

· Facilitate cost effective and quality patient care by effective communication with managerial team, physicians, and Medical Director

What are the requirements needed for this job?

· Excellent written and verbal communication skills

· Ability to communicate professionally with physicians and clients

· Ability to multi-task and quickly adapt in a fast-paced office environment

· Strong organizational skills with attention to detail

· Ability to problem solve complex, multifaceted, situations

· Experience with Microsoft products: Word, Excel, PowerPoint, Outlook

· Education, training or professional experience in medical and/or clinical practice

· Current LVN/RN license, without restrictions, from an accredited vocational nursing program (LVN) or a degree in nursing (RN) from an accredited college

What other skills/experience are we looking for?

· 3-5 years of clinical nursing experience (preferred)

· Prior experience in Utilization Management (preferred)

· Knowledge of ODG, MTUS, Milliman Care Guidelines, InterQual (preferred)