Clinical Reviewer, Utilization Management

University Health Careers; Hondo (TX); On-site; USD 70,000 - 95,000; Full time

Job summary

University Health Careers is seeking a Registered Nurse to support Community First Health Plan members, ensuring access to needed services efficiently, and coordinating care across the continuum. The role emphasizes collaboration with primary care physicians, family, resources, and other health care team members.

The ideal candidate holds an RN license in Texas, BSN or higher preferred, and at least 3 years in acute care, quality management, or managed care.

Qualifications

• Registered Nurse (RN) required.
• BSN or Master’s degree preferred.
• Minimum 3 years nursing, acute care, quality management or managed care experience required.

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.

Skills

Nursing

Care coordination

Medicaid/Medicare knowledge

Education

BSN preferred

Master’s degree preferred

Tools

InterQual

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.