Clinical Reviewer, Utilization Management

University Health; Hondo (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

University Health seeks a Registered Nurse to support Community First Health Plan members in regaining optimum health. You will oversee resource allocation, ensure access to necessary services, and coordinate care between primary care physicians, family, and community resources.

The ideal candidate holds an active RN license in Texas, with BSN or MSN preferred, and at least three years in nursing, acute care, quality management or managed care.

Qualifications

• RN required with current Texas licensure.
• BSN or Master’s degree preferred.
• Minimum 3 years nursing, acute care, quality or managed care experience.
• Basic knowledge of Medicaid/Medicare and community resources desired.
• Familiarity with InterQual criteria and DRG/ICD/CPT coding 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 benefit utilization.
• Collaborate with multidisciplinary health care team to identify educational and discharge needs.

Skills

Care coordination

Resource allocation

Quality management

Medicare/Medicaid knowledge

Medical coding awareness

Education

Registered Nurse (RN) license

BSN preferred

MSN preferred

Tools

InterQual criteria

DRG/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.