Clinical Reviewer, Utilization Management

University Health; San Antonio (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

University Health seeks an experienced RN Case Manager to oversee resource allocation, cost and quality of care for CFHP members. You will coordinate care across the primary care physician, family, resources, and the member to ensure efficient access to services across the care continuum.

Required is a TX RN license with BSN/MSN preferred and at least 3 years in nursing, acute care, or managed care. Knowledge of Medicaid/Medicare, InterQual, DRG/ICD/CPT coding is desirable.

Qualifications

• Active RN license in TX is required.
• BSN or MSN preferred for advanced scope.
• Minimum 3 years in nursing, acute care, quality management or managed care.

Responsibilities

• Oversee allocation of resources, cost and quality of care for members.
• Coordinate care among primary care physician, family, and member across continuum.
• Collaborate with multi-disciplinary team to identify educational and discharge needs.

Skills

InterQual criteria

DRG coding

ICD coding

CPT coding

Education

RN

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.