Equity Staffing is searching for a Remote Utilization Management Nurse (RN) in the State of Texas. This position is with a Fortune 100 organization. Our client serves more than 85 million people and has a reputation for bold ideas. If you enjoy working with energetic people in a collaborative environment, we want to speak with you!

*** Position is 100% Remote, WFH Opportunity, Candidate must reside in Texas ***

Specific Duties:

Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines.
Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria.
Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
Refers to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times.
Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member.
May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses.
Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to the Compliance Department.
Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies.
Documents rate negotiation accurately for proper claims adjudication.
Identify and refer potential cases to Disease Management and Case Management.
Performs all other related duties as assigned.
Must have qualifications/experience:

Active/Current Registered Nurse (RN) in Texas
Utilization Management Experience
Candidate must have completed the RN program and hold a RN degree
Having previous experience with bedside patient care
Experience with using Electronic Health Records application
Flexibility
Ability to work from home on a computer all day.
Self-motivated, highly collaborative, creative, and goal-oriented
Excellent time management and prioritization skills
Demonstrated awareness of when to appropriately escalate issues/risks
Problem Solving Skills
Experience working in a fast paced team environment
Great Multitasker
Positive Attitude
Good Typing Skills
Great Customer Service Skills
Attention to Detail
Strong Organizational Skills
Effective communication skills both written and verbal
Strong computer skills
Proficient in Microsoft Office Suite of Tools.
Critical thinking skills.
Ability to work with others.
Remote/Onsite: Remote in Texas

Shift Start/End Time: Monday-Friday 9am-6pm central (or as scheduled due to initiative) with rotating Saturday every 5 weeks

Equity Staffing Group is one of the fastest growing Native American owned staffing companies in the United States. We are a certified Minority Business Enterprise (MBE) by the National Minority Supplier Development Council (NMSDC) and the Rocky Mountain Minority Supplier Development Council (RMMSDC).

Equity Staffing Group is an Equal Employment Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law. Equity Staffing Group will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law.

We welcome you to learn more about our company by visiting www.equitystaffing.com.