Utilization Review Nurse

Job not on LinkedIn

🔥 15 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $82k - $95k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 2%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA)

WebsiteLinkedInAll Job Openings

51 - 200 employees

💼 Consulting

⚖️ Legal

🛡️ Insurance

Consulting • Legal • Insurance

Cobalt Benefits Group, LLC (DBA: Blue Benefit Administrators, CBA Blue & EBPA) is a full service Third Party Administrator (TPA) that specializes in the customization, marketing, and operation of self-funded employee benefit plans. With over 30 years of experience and a team of over 195 employees, CBG provides a wide array of products and services including self-funded medical and dental plans, Flexible Spending Accounts, Health Reimbursement Arrangements, and COBRA management. CBG aims to assist employers in building custom benefit plans while managing costs and ensuring compliance with regulations.

📋 Description

• Review clinical information to determine the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and levels of care • Evaluate healthcare services and facilities under applicable health benefit plans to ensure quality and cost-effective patient care • Collaborate with intake staff, physicians, specialists, case managers, and other care team members • Facilitate timely and effective care authorizations, transitions, and utilization determinations • Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria • Conduct medical necessity reviews for services requiring prior authorization • Request and evaluate clinical information needed to review requested services • Discuss cases and determinations with healthcare professionals and physician reviewers • Identify cases requiring intervention and collaborate with Case Managers • Maintain accurate documentation and comply with audit standards • Participate in team meetings, educational sessions, and related activities • Review medical claims and pre-determinations for medical necessity and appropriateness • Identify process improvement opportunities and enhance communication among departments • Consult with Physician Reviewers for complex or challenging cases

🎯 Requirements

• Current, unrestricted RN license (State license required) • Minimum 3 years of clinical nursing experience • Minimum 1 year of Utilization Management (UM) or Utilization Review (UR) experience • Strong analytical, critical thinking, and problem-solving skills • Proficiency in Microsoft Office Suite (Excel, Word, Outlook) • Familiarity with utilization management systems • Excellent verbal and written communication skills • Ability to interact effectively with internal and external stakeholders • Strong organizational and time management skills • Ability to handle multiple priorities independently • Comfort with being on camera for virtual meetings (e.g., Microsoft Teams) • Preferred: Experience with Milliman or Aetna criteria • Preferred: Background in healthcare administration, medical necessity determination, or benefits management • Preferred: Experience in data interpretation and medical trend analysis

🏖️ Benefits

• Fantastic medical, dental, and vision insurance • Twice annual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible • Company provided Basic Life and AD&D • Company paid Short-Term and Long-Term Disability • Flexible Spending Accounts • 401(k) Retirement Plan with up to a 6% employer-match • 100% fully vested after 3 years • 10+ paid holidays • Fully Paid half day Summer Fridays • Generous paid vacation and sick time • Annual Paid Volunteer Day • Annual Tuition Reimbursement • Annual Health and Wellness Reimbursement • Company events