Top 53 Utilization review nurse Jobs in Houston Tx

UTILIZATION REVIEW NURSE - RN
Nexus Health Systems Ltd —Houston, TX
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
Nurse - Clinical Review
HealthHelp - A WNS Company —Houston, TX
- $65,000 - $75,000 a year
- Email
- Remote
- Nursing
- Microsoft Excel
- LVN
- Health insurance
- Dental insurance
Quick Apply
Nurse, Concurrent Review
HealthHelp - A WNS Company —Houston, TX
- $75,000 a year
- Weekends as needed
- Remote
- Nursing
- Microsoft Excel
- RN License
- AD&D insurance
- Paid holidays
Quick Apply
11d
Case Manager-Registered Nurse (RN)-PRN
Houston Methodist Hospital —Houston, TX
- PRN
- Acute care
- Nursing
- Microsoft Excel
Case Manager-Registered Nurse (RN)
Houston Methodist Hospital —Houston, TX
- Part-time
- Acute care
- Nursing
- Microsoft Excel
8d
Case Manager-Registered Nurse (RN)
Houston Methodist Hospital —Houston, TX
- Full-time
- Acute care
- Nursing
- Microsoft Excel
Case Manager-Registered Nurse (RN)
Houston Methodist Hospital —Houston, TX
- Full-time
- Acute care
- Nursing
- Microsoft Excel
8d
House Supervisor (RN)Registered Nurse Behavioral Health
Westpark Springs —Richmond, TX
- Full-time
- Acute care
- CPR Certification
- Nursing
- Disability insurance
- Health insurance
Quick Apply
Hospice Case Manager, RN
Veritas Hospice & Palliative Care LLC —Stafford, TX
- Temporary
- Background check
- Vital signs
- Patient monitoring
Quick Apply
16h
Case Manager
Memorial Hermann Health System —Houston, TX
- Full-time
- Master of Social Work
- Nursing
- RN License
Hybrid MDS Nurse
Paradigm Healthcare LLC —Houston, TX
- Full-time
- Hybrid work
- Nursing
- Skilled nursing facility
- Microsoft Outlook
- Health insurance
- Dental insurance
Quick Apply
4d
Casemanager
Kelsey Sebold Foort Bend —Sugar Land, TX
- $25.53 - $45.00 an hour
- Full-time
- CPR Certification
- Addiction Medicine
- BLS Certification
- 403(b) matching
- Loan repayment program
Quick Apply
8d
Supp Case Mgr
Memorial Hermann Health System —Sugar Land, TX
- Part-time
- Master of Social Work
- Nursing
- RN License
Nurse Care Manager (Contract)
Suvida Healthcare —Houston, TX
- Contract
- Hybrid work
- Spanish
- Nursing
- RN License
Quick Apply
Staff Nurse Outpatient Clinic PHP/IOP CCKW
Carrus Health —Kingwood, TX
- RN License
- Computer literacy
- BLS Certification
Quick Apply
Supp Case Manager
Memorial Hermann Health System —Houston, TX
- Part-time
- Master of Social Work
- Nursing
- RN License
Care Coordinator- IRU
Texas Children's Hospital —Houston, TX
- Full-time
- Nursing
- RN License
- Customer service
Case Manager GRO /RTC
Grace Devine LLC —Houston, TX
- $20 - $25 an hour
- Full-time
- Background check
- CPR Certification
- Addiction Medicine
Quick Apply
11d
Nurse Care Manager
Suvida Healthcare —Houston, TX
- Full-time
- Hybrid work
- Spanish
- Nursing
- RN License
Quick Apply
VP Patient Flow & Care Transitions
Harris Health —Bellaire, TX
- $233,480 - $303,472 a year
- Full-time
- Microsoft Word
- Nursing
- Microsoft Excel

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utilization review nurse jobs near houston tx

UTILIZATION REVIEW NURSE - RN

Nexus Health Systems Ltd -
Houston, TX

Quick Apply

Job Details

Full-time

Qualifications

RN License
Managing patients as a nurse case manager
Acute care facility experience
Utilization management
Associate's degree
Associate Degree in Nursing

Full Job Description

POSITION SUMMARY:

The Utilization Review Registered Nurse (UR RN) is a key contributor to the delivery of appropriate, efficient, and cost-effective patient care. Working collaboratively within a multidisciplinary team, the UR RN conducts comprehensive reviews of clinical documentation, assesses medical necessity, and coordinates with healthcare providers and payers to support optimal patient outcomes and resource management. This role demands a solid clinical nursing background, sharp analytical skills, and a thorough understanding of regulatory standards and payer guidelines.

JOB-SPECIFIC RESPONSIBILITIES:

Service

o Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems

o Upholds the Standards of conduct and corporate compliance.

o Demonstrates honest behavior in all matters. To the best of the employee’s knowledge and understanding, complies with all Federal and State laws and regulations.

o Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.

o Adheres to all Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)

o Collaborates effectively with colleagues and other departments to ensure seamless service delivery.

o Maintain the highest level of confidentiality and professionalism in all interactions.

Excellence

o Conduct concurrent and retrospective reviews to assess the medical necessity of behavioral health services, ensuring compliance with payer specifications and organizational policies.

o Utilize evidence-based criteria (e.g., InterQual) to evaluate the appropriateness of care.

o Document utilization review activities accurately and timely within the electronic health record (EHR).

o Participate in weekly utilization review meetings to discuss cases, discharge plans, and barriers to discharge.

o Monitor key performance indicators (KPIs) and contribute to process improvement initiatives.

o Communicate effectively with all stakeholders across the health system.

o Demonstrate teamwork and collaboration to support a cohesive Utilization Review team.

o Provide coverage and support for team members as needed.

Patient Experience and Advocacy

o Educate treatment teams on comprehensive documentation practices to reflect patient status and treatment plans accurately.

o Collaborate with case management to address discharge planning, expected length of stay (ELOS), and potential barriers.

o Advocate for patients by ensuring access to necessary services and facilitating transitions to appropriate levels of care.

Quality Assurance and Compliance

o Ensure all activities adhere to healthcare regulations and organizational policies.

o Participate in quality improvement initiatives to enhance service delivery.

o Promotes a culture of patient safety which results in the identification and reduction of unsafe practices.

o Ensure adherence to applicable state and federal regulations, accreditation standards, and payer requirements.

o Participate in quality improvement, utilization management committees, and risk management activities.

o Perform ongoing quality assurance audits to evaluate the effectiveness of utilization review processes.

o Stay informed about changes in healthcare policies, regulations, and best practices related to utilization management.

Professional Growth and Continuing Education

o Completes annual education requirements.

o Maintains competency, as evidenced by completion of competency validation requirements.

o Maintains competency and knowledge of current standards of practice, trends, and developments.

o Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices.

o Engage in continuing education opportunities to maintain clinical competencies and stay current with industry standards.

o Attend departmental meetings, in-services, and training sessions as required.

o Pursue relevant certifications to enhance professional development and expertise in utilization review.

Finance

o Promotes stewardship of hospital resources while ensuring quality patient care.

o Manage denials and appeals processes, including evaluating root causes and developing strategies to minimize occurrences.

o Collaborate with internal departments to address unfunded days and work towards overturning denials.

o Facilitate authorization requests for level-of-care changes and insurance updates.

o Analyze utilization data to identify trends and opportunities for cost savings.

Performs other duties as assigned.

POSITION QUALIFICATIONS:

EDUCATION:

Associate Degree in Nursing (ADN) from an accredited institution required
Bachelor of Science in Nursing (BSN) from an accredited institution preferred.

EXPERIENCE:

Minimum of 2 years of clinical nursing experience in an acute care setting.
At least 3 years of experience in utilization review, case management with complex medical/surgical and/or behavioral health cases.
Experience with behavioral health services is advantageous.
2-3 years’ experience with InterQual or MCG preferred.

SKILLS: (new section)

Strong analytical and critical thinking abilities.
Excellent written and verbal communication skills.
In-depth knowledge of healthcare regulations, payer guidelines, and accreditation standards.
Ability to work independently and collaboratively within a team environment.
Effective time management and organizational skills.
Strong computer skills with demonstrated proficiency in electronic health records (EHRs) and utilization management software systems. Preferred experience with Meditech and Microsoft Office applications, including Outlook, Teams, Excel, Word, and SharePoint.

LICENSURE/CERTIFICATION:

Current and unrestricted Registered Nurse (RN) license in the State of Texas or compact license (required).
Certification in Case Management (CCM), Healthcare Quality (CPHQ), or Utilization Review (e.g., HCQM) is preferred.
Basic Life Support (BLS) certification as required for facility based staff; optional for remote staff.

Quick Apply

Refine Your Search

utilization review nurse jobs in houston tx

UTILIZATION REVIEW NURSE - RN

Nurse - Clinical Review

Nurse, Concurrent Review

Case Manager-Registered Nurse (RN)-PRN

Case Manager-Registered Nurse (RN)

Case Manager-Registered Nurse (RN)

Case Manager-Registered Nurse (RN)

House Supervisor (RN)Registered Nurse Behavioral Health

Hospice Case Manager, RN

Case Manager

Hybrid MDS Nurse

Casemanager

Supp Case Mgr

Nurse Care Manager (Contract)

Staff Nurse Outpatient Clinic PHP/IOP CCKW

Supp Case Manager

Care Coordinator- IRU

Case Manager GRO /RTC

Nurse Care Manager

VP Patient Flow & Care Transitions

I want to receive the latest job alert for utilization review nurse in houston tx

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