Utilization Review Nurse, RN

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🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🟢 Junior

👻 Ghost score 10%

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.

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Evry Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2017

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Evry Health is a modern, mobile-first health insurance company that provides fully insured employer health plans and personalized care teams. Built for midsize and larger employers (primarily in Texas), Evry offers no-copay, no-deductible plans, 24/7 virtual care, integrated wellness programs, and individualized support from nurses, nutritionists, and doctors to simplify costs and improve employee health. The company emphasizes a human, member-focused approach and digital tools (iOS/Android app) to deliver care and benefits.

📋 Description

• Provide comprehensive care coordination services across the care continuum • Prepare clinical reviews using clinical guidelines and present recommendations to physician reviewers for final determination • Conduct prior authorization, concurrent, and retrospective utilization management reviews • Support discharge planning, care coordination, clinical outcomes, and quality of care • Monitor clinical quality concerns, identify outlier and long-length-of-stay cases, and escalate complex issues • Interact with external facilities and providers to gather clinical information for medical necessity reviews and care plans • Assist with coding, medical records/documentation, pre-certification, reimbursement, and claim denials/appeals • Use active listening and motivational interviewing during member calls and document interactions • Assess and facilitate appropriate clinical programs and discharge planning following discharge • Manage departmental escalations through resolution and collaborate with the Medical Director on CM and UM cases • Participate in virtual team huddles, supervisor one-to-ones, instant messaging, check-ins, and member/provider calls

🎯 Requirements

• Must have a current, unrestricted Texas nursing license or Compact License; include license number(s) and corresponding state(s) in resume • Diploma from an accredited school/college of nursing required • 1-2 years of experience working at a health plan performing utilization management using standard practice guidelines • 3-5 years of clinical experience in a hospital or ambulatory setting assisting with direct patient care • Previous healthcare/managed care appeals experience • Working knowledge of medical and insurance industry terminology, including basic CPT/ICD10, authorizations, digital health programs, and NCQA/URAC standards • Experience outreaching and educating members telephonically • Ability to work independently in a fast-paced, deadline-oriented, tech-savvy work environment • Interest or experience in cardiology/pulmonology, women’s health, orthopedic surgery/physical medicine, primary care/pediatrics, or oncology • Required dedicated, private work area and secure handling of sensitive documents • High-speed internet connection/service • Must reside in the United States in the CST or EST time zones • Rotating on-call weekend availability for utilization review cases

🏖️ Benefits

• Comprehensive health, dental, and vision insurance as well as life and disability • Retirement savings plan with company match • Generous time off/vacation • Professional development opportunities • Flexible and remote work environment • Competitive salary