Clinical Reviewer, Utilization Management

University Health Careers; Seguin (TX); On-site; USD 65,000 - 85,000; Full time

Job summary

University Health Careers in Seguin, TX is seeking a Registered Nurse to support CFHP members in accessing the health services they need, through coordinated, efficient care. You will work across the care continuum with physicians, families, and community resources to optimize outcomes.

Texas RN licensure is required; BSN or Master’s degree preferred. A minimum of three years in nursing, acute care, quality management, or managed care is expected, with familiarity of Medicaid/Medicare and

Qualifications

• Registered Nurse licensure in Texas.
• Minimum 3 years in nursing, acute care, quality management or managed care.
• Knowledge of Medicaid/Medicare and community resources preferred.
• InterQual criteria, DRG, ICD and CPT knowledge preferred.

Responsibilities

• Oversee allocation of resources and monitor cost and quality of care.
• Coordinate care between the primary care physician, resources, family, and member.
• Coordinate care across the health care continuum while monitoring benefit utilization.
• Collaborate with multidisciplinary team to identify education and discharge needs.

Skills

Care coordination

Quality management

Medicaid/Medicare knowledge

Education

BSN

Master’s degree

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.