Clinical Reviewer, Utilization Management

University Health Careers; San Antonio (TX); On-site; USD 70,000 - 90,000; Full time

Job summary

University Health Careers is seeking an experienced registered nurse to oversee care coordination for CFHP members in Texas. The role ensures access to all needed health care services efficiently and effectively, collaborating with physicians, families, and community resources.

You will monitor utilization, guide discharge planning, and work with a multidisciplinary team to optimize educational and care outcomes for members.

Qualifications

• Registered Nurse (RN) is required.
• 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.

Responsibilities

• Oversee allocation of resources, cost and quality of health care for CFHP members.
• Coordinate care between primary care physicians, community resources, family and members.
• Coordinate care across the health care continuum while monitoring benefit utilization.
• Collaborate with multi-disciplinary health care teams to identify educational and discharge needs.

Skills

Care coordination

Medicaid/Medicare knowledge

InterQual screening criteria

DRG/ICD/CPT coding knowledge

Resource allocation

Education

RN required

BSN/MSN preferred

Tools

InterQual

DRG/ICD/CPT coding

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.