Utilization Review Nurse (LVN) - Managed Care
Pearland, TX (Houston Metro area)
**Full-Time, Benefits Available CONTRACT-TO-HIRE opportunity, expected to convert into a Permanent, Direct Hire role, after an established period! **
Utilization Review Nurse Job Summary:
Utilization Review Nurse Background:
- The Utilization Review Nurse is responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
- The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
- Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
- The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.
- Valid, unrestricted state Licensed Vocational Nurse (L.V.N.) license.
- Around 3 years of acute care, public health, or hospital nursing experience, preferably working with Geriatric patients.
- Requires minimum 2 years of prior authorization or utilization management experience at a Managed Care Organization (Health Plan/HMO/MSO/TPA/IPA/etc).
- Experience in and willingness to be part of multi-disciplinary team.
- Ability to interact within all levels of the organization as well as with external contacts.
- Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
- Bilingual in English and Spanish preferred.