Utilization Review Nurse

Nexus is actively recruiting to fill a Utilization Review Nurse position at our corporate headquarters in New Braunfels, Texas. This role is an amazing opportunity to grow and diversify your career within the healthcare arena. If you are interested in joining the Nexus team, access our application here.

Employee Application


Title:  Utilization Review Nurse

Job Summary
The primary function of the Utilization Review Nurse is to create an executive report by effectively reviewing and analyzing medical records. The executive report will include a summary, appropriate criteria/guidelines, and rationale.

Essential Job Functions:

  • Comprehension of medical/surgical modalities and imaging techniques
  • Analysis of clinical documentation in relation to medico-legal review
  • Collect data and analyze information to make decisions regarding certification or denial of treatment. Wok must be completely documented.
  • Audit and analyze patient records to ensure quality patient care and appropriateness of services
  • Utilize pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment (e.g. ODG, MTUS, Milliman Care Guidelines, Interqual)
  • Interpret and apply appropriate guidelines to medico-legal reviews
  • Use logic and reasoning to determine and utilize appropriate evidence based guidelines
  • Perform a low to moderate amount of research on a case by case basis
  • Create a high-quality, professional report free of grammar or spelling errors
  • Dictate all report information
  • Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims
  • Analyze information gathered by investigation and report findings and recommendations
  • Responsible for amending reports when necessary with any additional clinical information provided
  • Participates in an interdisciplinary health care team to achieve positive
  • Reach and maintain a 25-30 average daily case load once released from training
  • Maintain a monthly Quality Assurance score of 99% or higher
  • Requires regular and consistent attendance
  • Other duties as assigned

Knowledge and Abilities Requirements:

  • Knowledge of Basic Anatomy
  • Ability to use Microsoft products; Word, Excel, PowerPoint, Outlook
  • Basic office equipment experience preferred (copier, fax, shipping and receiving tools)
  • Written and verbal communication skills with a demonstrated ability to deliver excellent customer service
  • Communicate professionally with physicians and clients
  • Ability to multi-task and quickly adapt in a fast paced environment
  • Maintain a positive attitude and outstanding customer service while working closely internaly with Nexus staff, panel physicians and clients.
  • Strong organizational skills
  • Attention to detail
  • Professional appearance
  • General Typing Skills at 45wpm
  • Proficiency in English with an aptitude for spelling and grammar
  • Exemplary planning and time management skills
  • Ability to work in high pressure, deadline driven environment
  • Ability to multitask and prioritize daily workload
  • High level verbal and written communications skills
  • Discretion and confidentiality
  • Demonstrated ability to problem solve complex, multifaceted, situations
  • Ability to engage easily in abstract thought
  • Strong organizational and task prioritization skills

Education and Experience:

  • Degree in Nursing from an accredited college
  • Required to have education, training or professional experience in medical and/or clinical practice
  • A current license, without restrictions  (RN or LVN)
  • 3-5 years of clinical nursing experience (Preferred)
  • Prior experience in Utilization Management (Preferred)