Clinical Reviewer, Utilization Management

University Health Careers; Pleasanton (TX); On-site; USD 75,000 - 95,000; Full time

Job summary

Community First Health Plan (CFHP) is seeking an experienced Registered Nurse to oversee care coordination and resource allocation for members in Texas. The role includes coordinating care across the health care continuum and collaborating with multi-disciplinary teams to optimize outcomes.

The ideal candidate holds an RN license in Texas, a BSN or MSN is preferred, and a minimum of three years in nursing, acute care, quality management, or managed care is required.

Qualifications

• RN licensure in Texas is required.
• Bachelor of Science in Nursing (BSN) or Master’s degree preferred.
• Minimum 3 years nursing acute care, quality management or managed care experience.

Responsibilities

• Oversee allocation of resources, cost and quality of care for members.
• Coordinate care between primary care physicians, community resources, family and member.
• Collaborate with multi-disciplinary health care team to identify educational and discharge needs.

Skills

Care coordination

Quality management

Team collaboration

Communication

Education

BSN

MSN

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.