What are the responsibilities and job description for the Registered Nurse-Utilization Review position at TotalMed?
We are seeking a Utilization Review Registered Nurse for a travel assignment in Victoria, Texas
As a Utilization Review Registered Nurse (RN) supporting a health plan or insurance organization, you will use your clinical expertise to evaluate the medical necessity, appropriateness, and efficiency of healthcare services requested by providers. You'll serve as a critical liaison between healthcare providers and the health plan—helping to ensure that members receive the right care, in the right setting, at the right time. This role is a blend of clinical decision-making and administrative coordination, requiring strong communication skills and a solid understanding of medical guidelines and coverage policies.
Facility: Texas Independence Health Plan – Victoria
Assignment Type: Travel - Standard
Contract Length: 26 weeks
Shift: 0800 to 1700
Hours per Week: 40.00
Work Style: Onsite
Responsibilities
- Review prior authorization requests and clinical documentation to determine medical necessity and appropriate level of care.
- Apply utilization review criteria (e.g., InterQual, MCG) and plan policies to support coverage decisions.
- Collaborate with physicians, providers, and internal teams to obtain necessary documentation and clarify clinical details.
- Communicate determinations clearly and professionally to providers and members.
- Identify and escalate cases requiring physician review or medical director input.
- Document all review activities and decisions in accordance with regulatory and organizational standards.
- Participate in quality initiatives, audits, and policy updates to support continuous improvement.
Qualifications
- Current RN license
- BLS (other certifications as required by facility)
- Two years of recent Utilization Review RN experience
- Strong communication and adaptability skills
Salary : $38