Utilization Management Nurse

Ethos; Broussard (LA); On-site; USD 65,000 - 85,000; Full time

Job summary

Ethos is seeking a full-time Utilization Review Nurse to join our Medical Management Team in Broussard, LA. The role focuses on coordinating and managing utilization review processes, ensuring medical necessity, and issuing certifications when appropriate.

The nurse will provide clinical oversight to non-clinical staff, collaborate with providers, and support URAC standards while maintaining confidentiality and compliance across the program.

Qualifications

• Associate degree or higher in a healthcare field.
• RN license OR LVN/LPN certification required.
• 2+ years of clinical nursing experience required.
• Certification such as CCM/HCQM preferred.
• Experience in utilization review or medical management preferred.
• Excellent verbal and written communication.

Responsibilities

• Conduct timely utilization reviews for medical necessity and appropriateness.
• Evaluate continued or alternative treatment needs and discuss options with providers.
• Prepare clear case summaries and document in the UR system per URAC standards.
• Coordinate with peer reviewers and facilitate peer review discussions.
• Partner with providers to ensure cost-effective, high-quality patient care.
• Provide clinical guidance to non-clinical team members.
• Support Quality Management objectives and maintain confidentiality.
• Maintain compliance with regulatory and ethical standards.

Skills

Verbal communication

Written communication

Microsoft Office

Analytical skills

Organization

Negotiation

Confidentiality

Education

Associate degree or higher in healthcare

Tools

EHR systems

Job description

Ethos Risk Services is a leading insurance claims investigation and medical management company committed to providing better data that translates into better decision-making for our clients. We are at the forefront of innovation in our space, and our success is driven by a dynamic team passionate about delivering exceptional services to our customers.

JOB SUMMARY:

Our Ethos Medical Management Team is seeking a full-time Utilization Review Nurse for our Broussard, LA office to play a key role in coordinating and managing all aspects of the utilization review process. This position ensures that treatment requests are reviewed promptly and meet standards of medical necessity while promoting the best possible patient outcomes. The nurse will perform initial clinical reviews, issue certifications when appropriate, and elevate cases requiring peer review. This role also provides clinical oversight and guidance to non-clinical staff within the Utilization Management team.

KEY RESPONSIBILITIES:

• Conduct timely utilization reviews for medical necessity and appropriateness using approved evidence-based guidelines.
• Evaluate continued or alternative treatment needs and discuss options directly with requesting providers.
• Prepare clear and organized case summaries and document all components within the Ethos Utilization Management System per State, Federal, and URAC requirements.
• Coordinate with peer clinical reviewers and facilitate discussions during the peer review process.
• Partner with providers to ensure cost-effective, high-quality patient care.
• Offer clinical guidance and act as a resource to non-clinical team members.
• Support the company's Quality Management Program objectives and adhere to all Ethos policies and URAC standards.
• Maintain confidentiality and uphold compliance with all regulatory and ethical standards.

QUALIFICATIONS:

Education: Associate degree or higher in a healthcare field.

Licensure/Certifications:

• Registered Nurse License OR certificate in a healthcare field (LVN/LPN) required.
• Certified Case Manager (CCM), Health Care Quality & Management (HCQM), or similar certification preferred.

Experience:

• Minimum of 2 years of clinical nursing experience (direct patient care, administrative, or combined) required.
• Prior experience in utilization review, medical management, or workers' compensation preferred.

Skills:

• Exceptional verbal and written communication skills.
• Proficient in Microsoft Office Suite and electronic documentation systems.
• Strong analytical, organizational, and negotiation abilities.
• Ability to manage multiple priorities and work collaboratively in a team setting.
• Demonstrated discretion, professionalism, and commitment to confidentiality.

WORKING CONDITIONS:

This position is onsite in our Broussard, LA office. This position operates in a professional office environment with standard working hours. You'll spend extended periods at a computer, managing case reviews and documentation, and communicating frequently with providers, clients, and team members by phone and email.

Ethos Risk Services is an equal opportunity employer that does not discriminate on the basis of religious creed, sex, national origin, race, veteran status, disability, age, marital status, color or sexual orientation or any other characteristic

A background check will be conducted, in accordance to the local state law and regulations.