Utilization Manager Reviewer - Registered Nurse - RN - SWHR CIN - Remote - Sunday -Thursday

RN/Registered Nurse
21003452 Requisition #
138 Total Views

Southwestern Health Resources is seeking to hire a Utilization Manager Reviewer Registered Nurse to support our Southwestern Health Resources Utilization Management Department.


Location: Remote (Work from home), must live in Dallas-Fort Worth area or willing to relocate to be considered. Occasional meeting in office located at 1603 LBJ Freeway, Farmers Branch, Texas 75234


Salary range is $34.74/hour – Max 50.05/hour – based on relevant experience.


Work Schedule  

• Full-time: 40 hours per week, Sunday - Thursday 8am-5pm


The UM Reviewer RN is accountable for performing initial, concurrent, or post service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with Federal, State, Plan, and Accreditation standards. The UM reviewer serves as a liaison between providers/ facilities and Care Management Division. The essential job duties for this position are:


•  Supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff.

•  Accurately applies decision support criteria

•   Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.

•   Demonstrates an understanding of funding resources, services and clinical standards and outcomes.

•   Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.

•   Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement.

•  Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.

•  Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address

utilization/resource and progression of care issues. Assists in developing and implement an improvement plan to address issues.

•  Implement discharge plan to prevent avoidable days or delays in discharge.

•  Transition patient to next level of care in coordination with facility Discharge Planner.

•  Identify and refer complex risk members to case management.

•  Complete documentation timely, completely, and accurately in accordance with: (a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.

•  Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria, and/or appropriate level of care, and/or potential quality issues.

•  Perform other duties as assigned.

The ideal candidate will possess the following qualifications:

•  Associate's Degree Nursing required Or

•  Bachelor's Degree Nursing preferred

•  Master's Degree Nursing preferred

•  3 Years Utilization management experience in an acute or post-acute provider, health plan or other care company experience required and

•  2 Years of experience in direct patient care as an RN required

•  5 Years of experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management preferred.

 Recent or strong background in prior authorization preferably with Medicare or Medicaid experience.

•  Registered Nurse license upon hire required


•  Experience and knowledge of Milliman Guidelines or similar clinical guidelines preferred

•  Strong analytical and organizational skills

•  Working knowledge and ability to apply professional standards of practice in work environment.

•  Knowledge of specific regulatory, managed care requirements, and strong attention to detail.

•  Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc


Southwestern Health Resources Clinically Integrated Network (SWHR CIN) is a partner company of Texas Health. If hired for this position, you will become a SWHR CIN employee rather than a Texas Health employee.

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