Utilization Review Nurse

About You 

You thrive in a fast-paced environment. You’re curious and have an eye for detail. You strive to exceed expectations, and succeed. You’re excited by the opportunity to join a fast-growing company with unlimited opportunities for growth & competitive benefits. Does this sound like you? If so, Boon-Chapman could be the place for you! 

Job Responsibilities 

As a Utilization Review Nurse, your primary responsibility is to evaluate the medical necessity, appropriateness, and efficiency of healthcare services, ensuring optimal patient outcomes while adhering to payer guidelines. You will conduct prospective, concurrent, and retrospective reviews for various health services, including complex, high-cost procedures such as cancer treatments, hospitalizations, and surgeries. Your role will be pivotal in decision-making processes, including processing approvals, denials, and appeals. 

Key responsibilities may include: 

• Conduct utilization reviews for pre-certifications, prior authorizations, and continued stay determinations for inpatient and outpatient services, with a focus on high-cost, high-complexity cases such as cancer treatments and surgeries. 

• Apply medical necessity criteria using InterQual , NCQA, or other standardized clinical guidelines to ensure appropriate utilization of services. 

• Work closely with our Medical Director or independent physician reviewers on cases requiring further evaluation or when potential denials are identified, ensuring compliance with established policies and procedures. 

• Review and assess complex clinical cases, including high-dollar hospitalizations, extended surgeries, and specialized oncology treatments. 

• Ensure timely, accurate, and thorough reviews of cases that require a deep understanding of both clinical and payer guidelines. 

• Conduct retrospective reviews to ensure that billed services were appropriate and align with coverage policies. 

• Process and manage clinical appeals, providing rationale for denials and collaborating with the Medical Director for resolution when needed. 

• Participate in denial management by preparing clear, concise, and thorough denial letters and justifications. 

• Engage in effective communication with hospital utilization review departments, physician offices, and members to discuss authorization determinations and provide updates. 

• Serve as a resource for both internal teams and external providers, answering inquiries related to utilization management and care coordination. 

• Identify and refer appropriate plan members for case management, disease management, or other care navigation programs to ensure members receive timely and necessary care. 

• Uphold strict confidentiality standards, maintaining compliance with HIPAA and organizational policies. 

• Ensure that all reviews and communications align with state, federal, and payer-specific regulatory requirements. 

• Performs other duties as assigned. 

What We’re Looking For (Nobody’s Perfect, But Experience is a Plus!) 

• Registered Nurse (RN or BSN) with active, unencumbered license in the state of Texas (or compact state licensure). 

• Previous experience with Utilization Review, Utilization Management, Medical Management, or Case Management. Experience or exposure to complex case management, e.g. cancer treatments, high-dollar surgeries, and extended hospitalizations is helpful. 

• Working knowledge or understanding of InterQual, NCQA criteria, ICD-10, and CPT codes is helpful. 

• Familiarity with National Comprehensive Cancer Network guidelines is helpful.  

• Proficiency in Microsoft Office and various clinical software systems, with excellent organizational and multitasking skills. 

• Excellent written and verbal communication skills, with an ability to explain complex clinical information clearly to non-clinical stakeholders. 

• Clinical nursing experience helpful.  

Physical Requirements 

• Must be able to remain in a stationary position for 80% of the time. 

• Must use close visual acuity to perform an activity such as:  preparing and analyzing data and figures, transcribing, viewing a computer terminal and expansive reading. 

• Must be able to lift or move items up to 18lbs. 

• Must have the ability to move files, open filing cabinets and bend or stand as necessary. 

About Us 

At Boon-Chapman, our employees are our biggest asset. A few of our benefits include: 

• Paid holidays & competitive PTO that increases with tenure 

• Full benefits package including healthcare, dental, vision, 401(K), paid STD & life insurance and more 

• Casual everyday dress 

• The opportunity to work for a Top Workplace, according to Engage and the Austin American-Statesman 

Visit our website, www.boonchapman.com, to learn more. 

The job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Other duties, responsibilities and activities may change or be assigned at any time with or without notice 

Soluta, Boon-Chapman, Prime Dx is an equal opportunity employer committed to diversity and inclusion. We encourage qualified individuals from all backgrounds to apply.  

DISCLAIMER  

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is intended to provide guidelines for job expectations and the employee's ability to perform the position described. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. This document does not represent a contract of employment, and the company reserves the right to change this job description and/or assign tasks for the employee to perform, as the company may deem appropriate. 

with state, federal, and payer-specific regulatory requirements.

Qualifications:

• Registered Nurse (RN) license in the state of Texas (or compact state licensure).
• 2+ years of Utilization Review experience with specific experience in complex case management, including cancer treatments, high-dollar surgeries, and extended hospitalizations.
• Strong working knowledge of Interqual criteria, ICD-10, and CPT codes.
• Familiarity with National Comprehensive Cancer Network guidelines is highly preferred.
• Proficiency in Microsoft Office and various clinical software systems, with excellent organizational and multitasking skills.
• Excellent written and verbal communication skills, with an ability to explain complex clinical information clearly to non-clinical stakeholders.
• Clinical nursing experience (2-4 years) in a hospital, case management, or utilization management setting.