Nurse, Concurrent Review

Segwae; Houston (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Segwae in Houston seeks an experienced RN for concurrent inpatient utilization review using InterQual criteria to determine medical necessity for admissions, continued stays, and transitional care reviews. You will collaborate with physicians and care teams to support appropriate level-of-care decisions and ensure policy-compliant documentation.

The role requires an active RN license in the U.S., with 2+ years in acute care and utilization management preferred.

Qualifications

• RN with BSN preferred.
• Active unrestricted RN license in the United States.
• Two years of experience in an acute care setting.
• Two years in inpatient clinical nursing, utilization management, or case management (preferred).
• Experience with InterQual or similar criteria (preferred).
• Familiarity with inpatient vs observation status and transitional care planning (preferred).
• Working knowledge of medical necessity criteria and payer utilization review requirements.
• Proficient in Microsoft Office.
• Strong organizational, time management, and critical thinking skills.

Responsibilities

• Performs concurrent inpatient utilization review using InterQual criteria to determine medical necessity for admissions, continued stays, and transitional care reviews.
• Engages in clinical collaboration with attending physicians, hospitalists, and care teams to discuss determinations and support appropriate level-of-care decisions.
• Facilitates resolution of escalated cases and refers to Physician Reviewers or Medical Directors per guidelines.
• Maintains documentation per policy and ensures compliance with URAC, NCQA, HIPAA, and state/federal regulations.
• Collaborates with client personnel, provides quality customer service, and participates in the Quality Management Program.
• Schedule is 7AM–5PM PST / 9AM–7PM CST Monday–Friday with flexibility for weekends or alternative hours based on business needs.

Skills

InterQual knowledge

Microsoft Office

Critical thinking

Time management

Organizational skills

Education

RN degree (BSN preferred)

Tools

Microsoft Office

Job description

Responsibilities

Performs concurrent inpatient utilization review using InterQual criteria to determine medical necessity for admissions, continued stays, and transitional care reviews (SNF, IRF, LTACH). Engages in clinical collaboration with attending physicians, hospitalists, and care teams to discuss determinations and support appropriate level‑of‑care decisions. Facilitates resolution of escalated cases and refers to Physician Reviewers or Medical Directors per guidelines. Maintains documentation per policy and ensures compliance with URAC, NCQA, HIPAA, and state/federal regulations. Collaborates with client personnel, provides quality customer service, and participates in the Quality Management Program. Schedule is 7AM–5PM PST / 9AM–7PM CST Monday–Friday with flexibility for weekends or alternative hours based on business needs.

Qualifications

• RN graduate from an accredited school of nursing (BSN preferred).
• Current, active unrestricted RN license in a state or territory of the U.S.
• Two (2) years of experience in an acute care setting (required).
• Two (2) years of inpatient clinical nursing, utilization management, or case management experience (preferred).
• Experience with InterQual or similar evidence‑based clinical decision support criteria (preferred).
• Familiarity with inpatient level‑of‑care criteria, observation vs. inpatient status, and transitional care planning (preferred).
• Working knowledge of medical necessity criteria and payer‑specific utilization review requirements.
• Proficient in Microsoft Office (Word, Excel, PowerPoint).
• Strong organizational, time management, and critical thinking skills.