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Insurance Utilization Reviewer Jobs in Texas (NOW HIRING)

Oscar Health

Utilization Review Nurse

Dallas, TX · Remote

$35 - $45.94/hr

We're hiring a Utilization Review Nurse to join our Utilization Review team. About the role: You ... insurance, and paid wellness time and reimbursements. Artificial Intelligence (AI): Our AI ...

Bracane Co

Utilization Review Nurse

Plano, TX · Remote

... insurance or managed care industry using medically accepted criteria to validate the medical ... This position is responsible for performing initial, concurrent review activities; discharge care ...

HealthCare Support

Utilization Management

Houston, TX · On-site

$38 - $42/hr

Microsoft Office (Word, Outlook, Excel) Benefits for RN Outpatient Utilization Review Remote Texas: * Health Insurance * Dental Insurance * Life Insurance * Employee Assistance Program (EAP) * Access ...

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Insurance Utilization Reviewer information

What is an insurance utilization reviewer?

Insurance Utilization Reviewers are professionals who evaluate healthcare services to determine if they are medically necessary and covered by insurance policies. They review patient records, treatment plans, and insurance guidelines to ensure that the care provided aligns with established criteria and standards. Their work helps control healthcare costs, prevent unnecessary treatments, and ensure patients receive appropriate care. Utilization reviewers often communicate with healthcare providers and insurance companies to support or deny coverage decisions.

What are the key skills and qualifications needed to thrive as an insurance utilization reviewer, and why are they important?

To thrive as an Insurance Utilization Reviewer, you need a solid understanding of medical terminology, healthcare regulations, and insurance processes, usually supported by a clinical background or relevant certification. Familiarity with utilization review software, electronic health records (EHRs), and coding systems like ICD-10 and CPT is often required. Strong analytical thinking, attention to detail, and effective communication skills help reviewers assess medical necessity and coordinate with healthcare providers. These skills ensure accurate, efficient case evaluations and compliance with policies, which are crucial for optimizing patient care and managing healthcare costs.

What are some common challenges faced by insurance utilization reviewers, and how can they be addressed?

One of the primary challenges Insurance Utilization Reviewers face is balancing the need to adhere to strict insurance guidelines while advocating for appropriate patient care. Reviewers often handle high caseloads and must make timely decisions based on complex medical records, which requires strong attention to detail and up-to-date knowledge of coverage policies. Effective communication with healthcare providers and insurance representatives is also crucial to resolve discrepancies and ensure approvals. Staying organized, continuously updating clinical knowledge, and leveraging support from the utilization review team can help manage these challenges successfully.

What is the difference between Insurance Utilization Reviewer vs Insurance Claims Processor?

AspectInsurance Utilization ReviewerInsurance Claims Processor
Primary RoleReview medical necessity and appropriateness of services for insurance coverageProcess and review insurance claims for payment and accuracy
Required CredentialsOften requires healthcare or insurance certifications, such as RHIT or CPCTypically requires claims processing or insurance certifications, like CPC or CPC-H
Work EnvironmentHealthcare settings, insurance companies, or third-party administratorsInsurance companies, healthcare providers, or claims processing centers
Industry UsageCommonly employed in health insurance and managed careWidely used across health, auto, and property insurance sectors

The main difference is that Insurance Utilization Reviewers focus on evaluating the medical necessity of services, while Insurance Claims Processors handle the administrative processing of claims. Both roles require insurance-related certifications and are integral to the insurance industry, but they serve distinct functions in the claims and coverage review process.

What are popular job titles related to Insurance Utilization Reviewer jobs in Texas?

For Insurance Utilization Reviewer jobs in Texas, the most frequently searched job titles are:

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The top searched job categories for Insurance Utilization Reviewer jobs in Texas are:

What cities in Texas are hiring for Insurance Utilization Reviewer jobs?

Cities in Texas with the most Insurance Utilization Reviewer job openings:

Insurance Utilization Reviewer jobs near you

Utilization Management Reviewer FT

Lubbock, TX • On-site

StarCare Specialty Health System
Health Care and Social Assistance • 201 - 500 employees
Learn more about StarCare Specialty Health Systemexternal

Other

Medical, Life, Retirement, PTO

Re-posted 24 days ago

Job description

Description
StarCare Specialty Health System (StarCare) is seeking a full time Utilization Management (UM) Reviewer to join its outstanding Utilization Management team supporting the agency's various mental health authorization processes.
Responsibilities:
  • Provide Utilization Management functions in Mental Health Services.
  • Authorization of services based upon UM Guidelines.
  • Coordination and management of the Discharge Process.
  • Management of capacity related to Mental Health Service authorizations, and the management of the Mental Health Waiting Lists and Pre-Authorization Lists.
  • Conduct additional specific UM Reviews as needed.
  • Assist with the administrative functions of the UM Department.
  • Participate in the MAC Time Study as required and utilize Medicaid decision-making authority.
  • Complete all required documentation.
  • Communicate information to supervisor and other agency employees or vendors.
  • Assist with special projects or assignments as needed or as requested.
Schedule: This is a full-time/non-exempt position scheduled Monday - Friday, 8am - 5pm, with flexibility to meet the needs of the department. The position is based in Lubbock and will work in a hybrid work environment (combination of remote and on-site) and must be able to work on-site when job duties require or when requested by supervisor.
Benefit Package: StarCare offers an expansive benefit package including, but not limited to: Company-paid medical coverage, fully funded employer contribution to HSA, company-paid life insurance, company paid hospital indemnity plan, retirement plan with up to 12% employer match, front loaded paid time off (PTO), thirteen (13) paid holidays, sabbatical leave, longevity augmentations, and employee referral augmentations.
Qualifications:
  • Graduation from accredited four (4) year college or university with major course work in a Human Services Field (Psychology, Sociology, Family Studies, etc.)
  • Must have at least three (3) years of clinically appropriate experience in direct care for adults and/or children with serious mental illness or emotional disturbance and/or chemical dependency.
Skills & Abilities:
  • Knowledge and skill in operating standard office equipment and personal computer with Microsoft Office products is required.
  • Ability to communicate effectively, both orally, and in writing.
  • Ability to maintain an effective working relationship with other employees and the public.
  • Ability to organize and prioritize a variety of assignments and manage time effectively.
  • Ability to problem-solve and make decisions based upon specific criteria.
  • Knowledge of current healthcare standards.
  • Knowledge of appropriate rules, regulations, and policies and procedures.
  • Knowledge of general DSM-5 language and concepts.
  • Knowledge of the Mental Health Service Delivery system.
Additional Requirements:
  • Must pass a pre-hire drug screen and criminal background check.
  • Must have a Texas driver's license, liability auto insurance, and be insurable under the Agency's insurance.

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