Utilization Review Nurse

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🤠 Texas – Remote

🤠 Texas – Remote

💵 $90k - $98k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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

WebsiteLinkedInAll Job Openings

51 - 200 employees

Who We Are:

📋 Description

• Perform utilization and concurrent reviews of inpatient cases using Milliman, Aetna, and BCBS criteria. • Conduct medical necessity reviews for services requiring prior authorization, applying utilization-specific criteria. • 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 as needed. • Maintain appropriate and accurate documentation, ensuring compliance with audit standards. • Participate in team meetings, educational sessions, and related activities. • Review medical claims and pre-determinations for medical necessity and appropriateness. • Identify opportunities for process improvement 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) and familiarity with utilization management systems. • Excellent verbal and written communication skills, with the ability to interact effectively with internal and external stakeholders. • Strong organizational and time management skills, with the ability to handle multiple priorities independently.

🏖️ 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 • Half-day Summer Fridays • Generous paid vacation and sick time • Annual paid Volunteer Day • Annual Tuition reimbursement • Annual Health and Wellness reimbursement • Lots of fun company events