• Utilization Review Nurse - Case…

    Houston Methodist (The Woodlands, TX)
    At Houston Methodist, the Utilization Review Nurse (URN) PRN position is a licensed registered nurse (RN) who comprehensively conducts point of entry and ... resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position… more
    Houston Methodist (07/12/25)
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  • Sr Utiliz. Review Spclst Nurse

    Houston Methodist (Houston, TX)
    At Houston Methodist, the Sr Utilization Review Specialist Nurse (URSN) position is a licensed registered nurse (RN) responsible for promoting the ... an expert level at all objectives delineated in the Utilization Review Nurse and Utilization ...concern that may require clinical review during the pre-bill, audit , or appeal process. **GROWTH/INNOVATION ESSENTIAL FUNCTIONS** + Expands… more
    Houston Methodist (08/26/25)
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  • Clinical Appeals Nurse (RN)

    Molina Healthcare (San Antonio, TX)
    …outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse (RN) performs clinical/medical reviews of previously denied cases ... Medical Officer on denial decisions. + Resolves escalated complaints regarding Utilization Management and Long-Term Services & Supports issues. + Identifies and… more
    Molina Healthcare (08/15/25)
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  • Pharmacy Nurse - Licensed Vocational…

    STG International (Temple, TX)
    STGi is currently seeking a Pharmacy Nurse -Licensed Vocational Nurse to provide services at The William R. Courtney Texas State Veterans Home. The William R. ... drug regimen and report irregularities to DON 15. Randomly audit drug storage and medical supply areas to ensure...care in pharmacy ordering, alternative substitutions and off formulary utilization . 25. Participates as a team member in the… more
    STG International (07/31/25)
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  • Medical Claim Review Nurse (RN)

    Molina Healthcare (San Antonio, TX)
    …decision making pertinent to clinical experience + Documents clinical review summaries, bill audit findings and audit details in the database + Provides ... of payment decisions. + Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and Member/Provider Inquiries/Appeals. +… more
    Molina Healthcare (09/06/25)
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  • Initial Review Pharmacy Technician - Remote

    Prime Therapeutics (Austin, TX)
    …their staff, cardholders, and pharmacies. + Escalates medical exception requests to nurse , pharmacist or physician on the utilization review clinical team ... company achieving revenue goals and operational objectives. Responsible for executing utilization management programs on behalf of health plan/payor customers, while… more
    Prime Therapeutics (09/04/25)
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  • CM Delegation Liaison

    Molina Healthcare (TX)
    …Services (CMS), policies and procedures, quick reference guides (QRGs), audit tools and additional requirements during implementations. Attends all implementation ... to vendors as needed. * Assists in preparation of documents for utilization management, care management, state, CMS, NCQA and other regulatory audits as… more
    Molina Healthcare (09/05/25)
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  • State Director, Health Services

    BrightSpring Health Services (Houston, TX)
    …and responds to negative trends in performance metrics (outcomes, quality audit results, surveys, etc.) by assisting local operations and nursing leadership ... with local leadership in driving improvement in performance.* Ensures that there is a nurse on call after hours for all homes (and may participate in on-call duties… more
    BrightSpring Health Services (06/20/25)
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