Job Description

Job Description

Job Description

Description:

Job Summary

The Utilization Review Nurse is responsible for analyzing medical records for medical-legal reviews and producing high-quality, professional executive summaries. These reports must follow client-specific and evidence-based guidelines, incorporating clear rationales for determining medical necessity. The role involves prospective, concurrent, and retrospective review of inpatient and outpatient treatment, certifying medical necessity, and recommending appropriate lengths of stay. Reports must be thorough, accurate, and tailored to the specific requirements of each case and client.

Essential Job Functions:

• Analyze and interpret clinical documentation for medical-legal reviews

• Evaluate patient records to determine medical necessity and appropriateness of care using pre-approved guidelines (e.g., ODG, MTUS, InterQual, MCG)

• Draft clear, concise, and professional executive summaries that:

o Outline patient demographics and clinical course

o Summarize and assess treatment plans and physician orders

o Apply relevant evidence-based criteria

o Provide clear rationale and recommendations

• Ensure all reports are grammatically correct, free of spelling errors, and professionally formatted

• Dictate and finalize report content using designated systems

• Collaborate with physicians and clinical staff to clarify documentation or resolve discrepancies

• Amend reports as new clinical information becomes available

• Perform moderate research on a case-by-case basis to support findings

• Participate in interdisciplinary teams to support high-quality patient care outcomes

• Maintain a consistent caseload of 20 cases per day post-training

• Achieve and maintain a Quality Assurance (QA) score of 97% or higher

• Demonstrate consistent, reliable attendance and meet established deadlines

• Perform additional duties as assigned

Knowledge and Abilities Requirements:

• In-depth understanding of anatomy, medical/surgical modalities, and imaging techniques

• Strong knowledge of utilization review processes and criteria application

• Excellent written communication skills, with a strong focus on grammar, spelling, clarity, and organization

• Proven ability to analyze complex clinical information and apply critical thinking

• Familiarity with medical necessity guidelines (ODG, MTUS, MCG, InterQual)

• Ability to read and interpret clinical reports, technical documentation, and regulations

• High proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)

• Strong attention to detail and ability to meet high standards for accuracy

• Effective time management and multitasking skills in a deadline-driven environment

• Strong customer service orientation with the ability to communicate professionally with clients and providers

• Ability to maintain confidentiality and demonstrate sound judgment

• Ability to type a minimum of 45 WPM

• Excellent verbal and written communication skills in English

Qualifications :

• Active, unrestricted TX Registered Nurse (RN) license

• Minimum of 2–3 years of relevant clinical experience

• Prior experience in utilization review, case management, or medical-legal review preferred

License and Certification:

Current TX RN licensure, without restrictions

Driving Essential: No

Position Demands:

This position requires sitting, bending, and stooping for up to 8 hours per day in an office setting. Ability to lift and move objects weighing up to 10 lbs. Ability to learn technical material. The person in this position needs to occasionally move about inside the office to access file cabinets, office machinery, etc. Must be able to operate a computer and other office productivity machinery such as a calculator, copy machine, printer, etc. The person in this position frequently communicates with guests, team members, and vendors and must be able to exchange accurate information.

Equal Employment Opportunity (Our EEO Statement):

The Company is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The Company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. Team Members who believe they are the victims of discrimination should immediately report the concern to their Supervisor and Human Resources Department. Discrimination and harassment will not be tolerated.

We are committed to creating an inclusive environment for all Team Members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All company team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.

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