Clinical Reviewer, Utilization Management

University Health Careers; Boerne (TX); On-site; USD 60,000 - 90,000; Full time

Job summary

Community First Health Plan is seeking an experienced RN with strong care coordination skills to oversee resource allocation, quality of care, and timely access to services for members. The role requires collaboration with physicians, families, and community resources to optimize outcomes.

The candidate should have TX RN licensure, with BSN/MSN preferred, and at least 3 years in nursing or managed care. Knowledge of Medicaid/Medicare and InterQual criteria is highly-valued.

Qualifications

• Registered Nurse (RN) is required.
• Minimum three (3) years nursing, acute care, quality management or managed care experience is required.
• Knowledge of Medicaid, Medicare, community resources and alternate funding programs is desired.
• Knowledge of InterQual screening criteria as well as DRG, ICD and CPT coding is preferred.

Responsibilities

• Oversee allocation of resources, cost and quality of health care for members.
• Coordinate care between the primary care physician, community resources, family and member.
• Coordinate care across the health care continuum while monitoring and managing benefit utilization.
• Collaborate with multi-disciplinary health care team members in identifying the educational and discharge needs of members.

Education

RN licensure in Texas

BSN or MSN preferred

Job description

POSITION SUMMARY/RESPONSIBILITIES

Assists Community First Health Plan (CFHP) members regain optimum health or improved functional capacity by ensuring that members have access to all of the health care services they need in the most efficient and effective manner possible. Responsibilities include but are not limited to overseeing the allocation of resources, cost and quality of health care for members; coordinating care between the primary care physician, community resources, family and member; coordinating care across the health care continuum while monitoring and managing benefit utilization; and, collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members.

EDUCATION/EXPERIENCE

Registered Nurse (RN) is required. Bachelor of Science in Nursing (BSN) or Master’s degree is preferred. Minimum three (3) years nursing, acute care, quality management or managed care experience is required. Basic knowledge of Medicaid, Medicare, community resources and alternate funding programs is desired. Knowledge of InterQual screening criteria as well as DRG, ICD and CPT coding is preferred.

LICENSURE/CERTIFICATION

Current licensure as a Registered Nurse with the Texas State Board of Nurse Examiners is required. Current certification from an appropriate professional agency, such as Case Management Society, is preferred.