Utilization Management Nurse — Remote & Flexible Schedule

Harris Health; Houston (TX); On-site; USD 90,000 - 120,000; Full time

Job summary

Harris Health is seeking a Utilization Management Review Nurse to assess medical service necessity and optimize care across a large network in Texas. The role partners with Care Management, physician advisors, and payers to ensure appropriate care levels and cost-efficient outcomes.

The UMRN will review denials, assist with appeals, and conduct peer-to-peer reviews, drawing on clinical knowledge and guidelines.

Qualifications

• Strong analytical and mathematical skills for data-driven decision making.
• Solid understanding of medical terminology and care pathways.
• Experience with utilization review guidelines and payer processes.

Responsibilities

• Evaluate necessity and appropriateness of medical services and facilities.
• Collaborate with Care Management, Physician Advisors, and payers to ensure appropriate care levels.
• Reconcile denials, assist with appeals, and arrange peer-to-peer reviews as needed.
• Collect and analyze variances from the plan of care with clinicians.

Skills

Analytical

Mathematics

Medical Terms

Education

Bachelor of Science in Nursing

Tools

InterQual

Change Healthcare

Job description

Harris Health is seeking a Utilization Management Review Nurse to assess medical service necessity and optimize care across a large network in Texas. The role partners with Care Management, physician advisors, and payers to ensure appropriate care levels and cost-efficient outcomes.

The UMRN will review denials, assist with appeals, and conduct peer-to-peer reviews, drawing on clinical knowledge and guidelines.