RN Clinical Reviewer: Utilization & Care Coordination

University Health; Seguin (TX); On-site; USD 65,000 - 95,000; Full time

Job summary

University Health seeks an experienced registered nurse to support CFHP members by coordinating access to care, resources, and services across the health care continuum to achieve optimal outcomes.

The role emphasizes utilization management, discharge planning, and collaboration with a multidisciplinary team to educate members, coordinate care with physicians, families, and community resources, and ensure efficient, high‑quality care.

Qualifications

• RN is required.
• BSN or Master’s degree 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

• 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.
• Collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members.

Skills

Registered Nurse

Care coordination

Medicare/Medicaid knowledge

Education

BSN or MSN preferred

Job description

University Health seeks an experienced registered nurse to support CFHP members by coordinating access to care, resources, and services across the health care continuum to achieve optimal outcomes.

The role emphasizes utilization management, discharge planning, and collaboration with a multidisciplinary team to educate members, coordinate care with physicians, families, and community resources, and ensure efficient, high‑quality care.