Clinical Reviewer, Utilization Management

University Health; Boerne (TX); On-site; USD 70,000 - 90,000; Full time

Job summary

University Health is seeking a skilled Registered Nurse to join our care coordination team in Texas. This role focuses on ensuring access to necessary health services and coordinating care across the continuum to optimize outcomes.

Responsibilities include resource allocation, quality and cost management for members, interfacing with primary care physicians, families, and community resources, and collaborating with a multidisciplinary team to plan effective discharge and educational needs.

Qualifications

• Registered Nurse (RN) licensure in Texas required.
• Minimum three years nursing or related experience in acute care/quality management/managed care.
• Basic knowledge of Medicaid/Medicare and community resources.

Responsibilities

• Oversee allocation of resources, cost and quality of health care for members.
• Coordinate care between the primary care physician, family, community resources and member.
• Coordinate care across the health care continuum while monitoring benefit utilization.
• Collaborate with a multidisciplinary health care team to identify educational and discharge needs.

Skills

Care coordination

Resource management

Quality improvement

Case management

Education

RN licensure (TX)

BSN preferred

Master's degree preferred

Tools

InterQual criteria

ICD/CPT coding knowledge

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.