Utilization Management Nurse (Dallas/Hybrid WFH)

ABOUT US

Ethos Risk Services is a leading insurance claims investigation and medical management company committed to providing better data that translates into better decision-making for our clients. We are at the forefront of innovation in our space, and our success is driven by a dynamic team passionate about delivering exceptional services to our customers.

JOB SUMMARY

Our Ethos Risk team is seeking a full-time Utilization Management (UM) Nurse for a hybrid schedule (2-3x in the Dallas, TX office) to coordinate all components of the utilization review process, ensuring timely review of treatment requests for medical necessity, promoting cost-effective treatment, and achieving the best patient outcomes. This role involves performing initial clinical reviews, preparing case summaries, issuing certifications of medical necessity, and escalating cases for peer clinical review when necessary.

KEY RESPONSIBILITIES:

• Coordinate the utilization review process for each treatment request.
• Provide clinical oversight and serve as a resource for non-clinical staff.
• Conduct initial clinical reviews for medical necessity against approved evidence-based guidelines.
• Evaluate the need for continued or alternative treatment with providers.
• Discuss treatment options with requesting providers.
• Document utilization review components within the Ethos Utilization Management System per State, Federal, and URAC requirements.
• Refer, coordinate, and interact with peer clinical reviewers.
• Facilitate peer discussions during the peer clinical review process.
• Partner with medical providers to promote best patient outcomes.
• Adhere to Ethos Policies and Procedures and URAC standards.
• Assist in promoting and furthering the objectives of the Quality Management Program.
• Maintain confidentiality and security in all aspects of performance.
• Perform other related duties incidental to the work described.

QUALIFICATIONS

Education/Licensure/Certification:

• Completion of formal training in a healthcare field.
• Active unrestricted professional license or certification to practice as a health professional in a state or territory of the United States:
• An associate degree or higher in a healthcare field (RN) OR State license or state certificate in a healthcare field (LVN/LPN)
• Certified Case Manager (CCM), Health Care Quality & Management (HCQM), or equivalent certification preferred.

Skills:

• Knowledge of workers' compensation laws and regulations (preferred).
• Discretion and confidentiality.
• Good customer service skills.
• Strong oral and written communication skills.
• Proficiency in computer usage, including Microsoft Office products.
• Ability to perform as part of a team.
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