19002- Registered Nurse

Richardson, TX 75082

Posted: 01/17/2023 Industry: Other Job Number: 39429

Job Description

Registered Nurse

Duration: 6 Months+

Job Responsibilities:
  • This position is responsible for ensuring compliance of the Utilization Management (UM) and Quality Review (QR) functions for Medicare. Creates, reviews and documents clinical decision-making criteria for case submission to Independent Review Entity.

  • Reviews and evaluates clinical criteria against regulatory policies for accurate decision making
  • Creates clinical packets for submission ensuring correct use of utilization management, quality review, clinical, and non-clinical quality improvement.
  • Monitors and participates in clinical case audits. Evaluates results, prepares reports on findings, and communicates outcomes to leadership
  • Provides necessary administrative support to assist Medical directors and staff in clinical case reviews
  • Communicates trends and overall program performance to management.
  • Participates on various related committees as necessary.
  • Communicate and interact effectively and professionally with co-workers, management, customers, etc.
  • Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
  • Maintain complete confidentiality of company business.
  • Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

  • Registered Nurse (RN) or LPN with unrestricted license in Texas.
  • 3 years clinical experience with 2 years experience in utilization review, case management, quality assurance
  • Clinical knowledge and knowledge of managed care principles - Medicare and Medicaid
  • Clinical analysis skillset to include clinical decision-making review and application of clinical criteria
  • Analytical, verbal and written communications skills.
  • Must be proficient in MS Office (Excel and Adobe included)
  • Must be PC, laptop proficient
  • CMS, NCQA, Medicaid knowledge is a plus


Job Requirements


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Jordyn Dare

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