Houston Pre-Cert Nurse/UR Nurse

About the role

The PreCert Nurse - LVN Utilization Review Nurse (Administrative Nursing) position at Nexus offers a diverse and rewarding career path. Nexus connects healthcare professionals with industry partners, focusing on delivering quality, accurate medical care efficiently and cost-effectively.

Responsibilities

• Perform a review of services for medical appropriateness using pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment (e.g., ODG, MTUS, Milliman Care Guidelines, InterQual)
• Audit and analyze patient records to ensure quality patient care and necessity of services
• Provide clinical knowledge and act as a clinical resource to non-clinical staff
• Enter and maintain pertinent clinical information in various medical management systems
• Maintain knowledge of regulatory requirements (i.e., URAC), and state utilization review standards
• Use clinical logic and reasoning to determine appropriate evidence-based guidelines
• Facilitate cost-effective and quality patient care by effective communication with managerial team, physicians, and Medical Director

Requirements

• Excellent written and verbal communication skills
• Ability to communicate professionally with physicians and clients
• Strong organizational skills with attention to detail
• Ability to problem solve complex, multifaceted situations
• Experience with Microsoft products: Word, Excel, PowerPoint, Outlook
• Current LVN/RN license, without restrictions, from an accredited vocational nursing program (LVN) or a degree in nursing (RN) from an accredited college

Skills

• 3-5 years of clinical nursing experience (preferred)
• Prior experience in Utilization Management (preferred)
• Knowledge of ODG, MTUS, Milliman Care Guidelines, InterQual (preferred)