Assistant Director, Utilization Review (On-site)

Nexus Enterprises, LLC; Schertz (TX); On-site; USD 90,000 - 120,000; Full time

Job summary

Nexus Enterprises, LLC in Schertz, TX seeks an Assistant Director of Utilization Review to lead the UR team, supervise staff, and drive data-driven process improvements. The role partners with the Director to oversee production metrics and regulatory compliance.

The position emphasizes analysis of complex data, coordination of pre-authorization and retrospective reviews, and development of training initiatives to enhance nurse performance and retention.

Qualifications

• BSN with 1-2 years' experience in a Managed Care setting.
• Experience with various state evidence-based medicine guidelines.
• Experience in a previous management role is preferred.
• Proficient computer skills; able to navigate through multiple software systems; knowledge of Microsoft Word, Excel, and Outlook.

Responsibilities

• Lead, supervise, and train the Utilization Review team in partnership with the Director, Utilization Review; ensure optimal workload distribution and performance.
• Analyze data for individual performance evaluations of UR Nurses.
• Establish and monitor workflow processes and production goals; collect, analyze, and report complex metrics.
• Stay current with regulatory changes and communicate updates to UR Nurses.
• Develop strategies for nurse retention and incentive programs; designs educational initiatives.
• Assist in case audits for nurses in training and provide actionable insights for quality development.
• Distribute cases during training to ensure exposure to different categories, clients, and state guidelines.
• Support call coverage and address questions during nurses' initial training period.
• Conduct intermittent utilization and quality reviews; participate in pre-authorization, concurrent, and retrospective reviews.

Skills

Leadership

Data analysis

Report writing

Medical terminology

Regulatory understanding

Communication

Education

BSN

Managed Care experience

Tools

Microsoft Word

Excel

Outlook

Job description

Description

Job Title: Assistant Director, Utilization Review

Company: Nexus

Department: Utilization Review

FLSA Status: Exempt

Work Location: Onsite, Schertz, TX

Reports To: Director, Utilization Review

Our Mission

We are driven by a shared mission to improve the quality of life for all people we serve. This mission guides every aspect of our work and is embedded in the fabric of our daily operations, leadership, and service delivery.

Job Summary

The Assistant Director, Utilization Review plays a pivotal role in partnering with the Director, Utilization Review to lead, supervise, and train the utilization review team. This position blends leadership with analytical expertise in the collection, aggregation, analysis, and reporting of complex production data to ensure operational excellence. The data will be used to drive smarter allocation of administrative nursing resources and fuel continuous improvement in review processes.

Essential Job Functions

• Works in partnership with the Director, Utilization Review to provide leadership, supervision, training, and direction for the Utilization Review Department, ensuring optimal workload distribution and team performance.
• Collaborates with the Director, Utilization Review to gather and analyze data for comprehensive, individual performance evaluations for each Utilization Review Nurse.
• Partners with the Director, Utilization Review to establish and monitor workflow processes and production goals. Including the collection, aggregation, analysis, and reporting of complex production metrics.
• Maintains up-to-date knowledge of regulatory changes and ensures timely communications of updates to Utilization Review Nurses.
• Works jointly with the Director, Utilization Review to develop strategies for nurse retention and incentive programs.
• Partners with the Director, Utilization Review to design and implement educational initiatives.
• Assists the Director, Utilization Review in case audits for nurses in training, offering direct guidance to promote quality standards and actionable insights for quality development.
• Collaborates with the Director, Utilization Review in distributing cases during training, providing equitable opportunities for exposure to different request categories, clients, and state guidelines and requirements.
• Collaborates with the Director, Utilization Review to support call coverage and address questions from nurses undergoing their initial four-week training period.
• Conducts intermittent utilization and quality reviews.
• Performs pre-authorization, concurrent, and retrospective reviews dealing with Medical Necessity from the Workers' Comp system, Group Health, Disability, etc. The review requires and includes evaluation of clinical data documented in laboratory reports, radiology reports, and multidisciplinary progress notes.
• Perform a low to moderate amount of research on a case-by-case basis.
• Produce high-quality, professional reports with impeccable grammar and spelling.
• Dictates all report information.
• Communicate and coordinate successfully with team members and vendors in both spoken and written formats.

Requirements

• Ability to read, analyze, and interpret documents, reports, technical procedures, governmental regulations, and correspondence.
• Proficient in producing clear, accurate reports, formal correspondence, and training materials for diverse audiences, with the ability to convey information effectively to management, staff, and all other stakeholders.
• Proficiency in grammar, spelling, punctuation, and document formatting, with strong oral and written communication skills.
• Comprehension of medical/surgical modalities and imaging techniques.
• Ability to analyze clinical documentation in relation to medico-legal review.
• Ability to interpret and apply appropriate guidelines to medico-legal reviews.

Education and Experience

• BSN with 1-2 years' experience in a Managed Care setting.
• Experience with various state evidence-based medicine guidelines.
• Experience in a previous management role is preferred.
• Proficient computer skills; able to navigate through multiple software systems; knowledge of Microsoft Word, Excel, and Outlook.

License and Certification

• Must hold a current and unrestricted RN license.

Driving Essential

• No

Position Demands

• Sit or stand to complete assigned work on a computer and with other standard office technology. An ergonomic workspace is provided for both options.
• Use hands and fingers to operate a keyboard, mouse, and other applicable office equipment.

Equal Employment Opportunity (Our EEO Statement)

The Company is a veteran-owned Company and provides Equal Employment Opportunities (EEO) to all Team Members and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender (including gender identity), pregnancy, childbirth, or a medical condition related to pregnancy or childbirth, national origin, age, disability, genetic information, status as a covered veteran in accordance with applicable federal, state, and local laws, or any other characteristic or class protected by law and is committed to providing equal employment opportunities. The Company complies with applicable state and local laws governing non-discrimination in employment. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, promotion, discharge, pay, fringe benefits, membership, job training, classification, and other aspects of employment. Team Members who believe they are the victims of discrimination should immediately report the concern to their Supervisor and the Human Resources Department. Discrimination and harassment will not be tolerated.

We are committed to creating an inclusive environment for all Team Members and applicants. We value the unique skills and experiences that veterans bring to our team and encourage veterans to apply.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of our personnel. All company team members may be required to perform duties outside of their normal responsibilities from time to time, as needed.