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Insurance Utilization Reviewer Jobs in Texas (NOW HIRING)

CommonSpirit Health

Utilization Review RN

Houston, TX · On-site

$41.14 - $61.20/hr

Utilization Review RN Inspired by faith. Driven by innovation. Powered by humankindness ... insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid ...

Houston Methodist

Recent work experience in a hospital or insurance company providing utilization review services * Knowledge of Medicare, Medicaid, and Managed Care requirements * Progressive knowledge of community ...

Acadia Healthcare

Utilization Specialist - FT

El Paso, TX · On-site

Proactively monitor utilization of services for patients to optimize reimbursement for the facility ... Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ...

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Insurance Utilization Reviewer information

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 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 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 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 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:
What job categories do people searching Insurance Utilization Reviewer jobs in Texas look for? The top searched job categories for Insurance Utilization Reviewer jobs in Texas are:
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Insurance Utilization Reviewer jobs near you

Utilization Review Nurse (55697)

El Paso Children's Hospital

El Paso, TX • On-site

Other

Re-posted 16 days ago

El Paso Children's Hospital rating

7.5

Company rating: 7.5 out of 10

Based on 12 frontline employees who took The Breakroom Quiz

299th of 1,055 rated hospitals

Job description

Utilization Review Nurse

San Jacinto Plaza - Sunflower Building - El Paso, TX 79901; El Paso Childrens Hospital - El Paso, TX 79905

Overview

Level Experienced Position Type Full Time Job Shift Day Education Level 4 Year Degree Category Health Care

Description

To monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services. Responsible for ensuring the appropriateness of hospital admissions and extended hospital stays. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are the key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate and arrange peer to peers when clinical denials related to medical necessity of the patient while hospitalized. UM nurse will work closely in collaboration with physician advisers to support policy development, and process improvement.

Qualifications

Work Experience:

  • Two (2) years prior experience with Utilization Management.
  • Previous training and demonstrated competence in negotiations, quality assurance, case management outcomes, and keyboarding/computer use.
  • Experience with InterQual and/or Milliman Care Guidelines. Strong organizational and time management skills.
  • Ability to work on extremely complex problems where analysis of situation or data requires an evaluation of intangible variance factors.

License/Registration/Certification:

  • Current RN License to practice in the State of Texas.

Education and Training:

  • Associate's Degree in Nursing, BSN preferred.

Skills:

  • Ability to utilize proficient verbal, written and interpersonal communication skills.
  • Ability to work on extremely complete problems where analysis of situations or data requires an evaluation of intangible variance factors.
  • Knowledge of managed care, reimbursement and utilization management.
  • Knowledge of current International Classification of Disease (ICD-10), Diagnostic Related Groups (DRGs), and medical necessity criteria.
  • Knowledge of claims denials and appeals processing
  • Ability to coordinate and manage multiple priorities, projects simultaneously, reprioritizing as necessary
  • Ability to self-motivate, multi-task and prioritize in a fast paced environment.
  • Ability to use analytical and problem solving skills.
  • Knowledge of HIPAA standards.
  • Knowledge of various insurance plan coverages for Home Health, DME, SNF, LTAC agencies.
  • Works well with people of all social, economic, and cultural backgrounds.
  • Strong customer service orientation.
  • Knowledgeable regarding community resources.
  • Knowledge of basic computer, word-processing, and spreadsheet skills, Microsoft.
  • Ability to operate standard office equipment.
  • Knowledge of English grammar, punctuation and spelling.

What El Paso Children's Hospital employees say

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