Utilization Review Nurse

Job Title: RN Clinical Review Nurse (Utilization Review Nurse)

Job Description

The Clinical Review Clinician for Appeals is responsible for performing clinical reviews to resolve and process appeals by examining medical records and clinical data. This role ensures that medical necessity for services is determined in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.

Responsibilities

• Prepare case reviews for Medical Directors by researching appeals, reviewing applicable criteria, and analyzing the basis for the appeal.
• Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards.
• Communicate with members, providers, facilities, and other departments regarding appeal requests.
• Generate appropriate appeals resolution communication and reporting for members and providers in accordance with company policies, State, Federal, and NCQA standards.
• Work with leadership to increase the consistency, efficiency, and appropriateness of responses to all appeal requests.
• Partner with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Perform other duties as assigned.
• Comply with all policies and standards.

Essential Skills

• Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
• 2-4 years of related experience.
• Knowledge of NCQA, Medicare, and Medicaid regulations.
• Knowledge of utilization management processes.

Work Environment

The role involves collaboration with a team of over 30 clinicians in the Medicare Appeals team. You will complete clinical reviews for preservice authorization denials and retrospective claim denials to determine medical necessity. The position supports continuity of service during a department BPO launch and recent staff turnover. You will complete clinical reviews for assigned cases through a round-robin distribution, update and process authorizations using InterQual, and communicate with MD reviewers, supervisors, and coordinators on determinations. Communication via Teams is used for quick questions and workflow alignment.

This is a Contract position based out of Houston, TX.

The pay range for this position is $30.00 - $40.00/hr.

Individual compensation offered for this position within this range will depend on many factors, including qualifications, skills, relevant experience, job knowledge, geographic location, internal equity, and other pertinent job-related factors.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

This is a fully remote position.

This position is anticipated to close on Aug 31, 2026.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 20,000 consultants and 5,000 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500. We are proud to be an Engineering News-Record (ENR) Top 500 Design Firm for our engineering design services and a ClearlyRated Best of Staffing® winner for both client and talent service.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.

Salary : $30 - $40