Clinical Reviewer, Utilization Management

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

Job summary

University Health is seeking a Registered Nurse to oversee case management for Community First Health Plan (CFHP) members, ensuring access to needed services and coordinated care across the health system.

The role focuses on resource allocation, cost and quality oversight, and collaboration with primary care physicians, family, members, and multidisciplinary teams to identify educational and discharge needs within the continuum of care.

Qualifications

• RN is required.
• BSN or MSN preferred.
• Minimum three years nursing, acute care, quality management or managed care experience.
• Knowledge of Medicaid, Medicare, community resources and alternate funding programs is desired.
• Knowledge of InterQual criteria, DRG, ICD and CPT coding is preferred.

Responsibilities

• Oversee allocation of resources, cost and quality of health care for CFHP 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 to identify educational and discharge needs of members.

Skills

Case management

InterQual criteria

ICD/CPT coding

Nursing

Education

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.