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Utilization Management Auditor Jobs in Texas (NOW HIRING)

Gonzaba Medical Group

UM Nurse

San Antonio, TX · On-site

Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.

Gonzaba Medical Group

UM Nurse

San Antonio, TX · On-site

Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.

Gonzaba Medical Group

UM Nurse

San Antonio, TX

Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk ... Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management.

Hendrick Medical Center

Coding Auditor

Abilene, TX · On-site

$26.25 - $30/hr

... of disease pathophysiology and drug utilization Knowledge of MS-DRG classification and ... time management and assignment completion Ability to work in a virtual setting under minimal ...

Daikin

Auditor 2

Waller, TX

The Internal Auditor 2 conducts financial and operational audits by verifying and examining ... management during and at the completion of examinations, reporting asset utilization and audit ...

Daikin

Auditor 2

Waller, TX

The Internal Auditor 2 conducts financial and operational audits by verifying and examining ... management during and at the completion of examinations, reporting asset utilization and audit ...

Daikin

Auditor 2

Waller, TX · On-site

... management during and at the completion of examinations, reporting asset utilization and audit ... Auditors (IIA) and the American Institute of Certified Public Accountants (AICPA). • Ability to ...

University Health

Coding Educator/Auditor

San Antonio, TX · On-site

$25.10 - $40.25/hr

Works under the direct supervision of the Coding Education & Audit Manager. Will perform any or a ... Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). Duties:

University Health

Coding Educator/Auditor

San Antonio, TX · Remote

$25.10 - $40.25/hr

Works under the direct supervision of the Coding Education & Audit Manager. Will perform any or a ... Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC). Duties:

University Health

Coding Educator/Auditor

San Antonio, TX

$23.50 - $26.75/hr

... metrics, Utilization Review Accreditation Commission (URAC), and the Joint Commission (TJC ... Associate's degree in Health Information Management and/or Bachelor's degree is preferred.

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Utilization Management Auditor information

What is the difference between Utilization Management Auditor vs Utilization Review Nurse?

AspectUtilization Management AuditorUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications like CCM or CUCLicensed Registered Nurse (RN), often with additional certifications
Work EnvironmentOffice-based, insurance companies, healthcare organizationsHospital, clinics, insurance companies, often in clinical settings
Primary FocusAuditing and reviewing utilization data for compliance and cost managementAssessing patient care needs and determining appropriate services

While both roles involve healthcare utilization, the Utilization Management Auditor primarily reviews data for compliance and cost efficiency, whereas the Utilization Review Nurse focuses on patient care assessments. Both require nursing credentials and work within healthcare or insurance settings, but their core responsibilities differ.

What are some common challenges faced by utilization management auditors and how can they be addressed?

Utilization Management Auditors often encounter challenges such as keeping up with constantly changing healthcare regulations and payer requirements, interpreting complex medical documentation, and ensuring compliance with both internal and external policies. To address these challenges, auditors should engage in ongoing professional development, collaborate closely with clinical and administrative teams for accurate information, and make use of robust audit tools and resources. Effective communication and a proactive approach to regulatory changes can help streamline the audit process and maintain high standards of accuracy.

What is a utilization management auditor?

A Utilization Management Auditor is a healthcare professional responsible for reviewing medical records, claims, and utilization data to ensure that healthcare services provided to patients are necessary, appropriate, and comply with established guidelines and policies. They help identify overuse, underuse, or misuse of medical resources and ensure regulatory compliance. Utilization Management Auditors work closely with healthcare providers, insurance companies, and regulatory agencies to improve the quality and cost-effectiveness of patient care.

What are the key skills and qualifications needed to thrive as a utilization management auditor?

To thrive as a Utilization Management Auditor, you need a strong background in healthcare administration, case management, and medical coding, often supported by a clinical degree or certification such as RN, LPN, or RHIA. Familiarity with utilization management software, electronic health records (EHRs), and regulatory standards like CMS guidelines is essential. Analytical thinking, attention to detail, and effective communication are crucial soft skills for identifying compliance issues and collaborating with healthcare teams. These skills ensure accurate audits, regulatory compliance, and optimal resource utilization within healthcare organizations.
What are popular job titles related to Utilization Management Auditor jobs in Texas? For Utilization Management Auditor jobs in Texas, the most frequently searched job titles are:
What job categories do people searching Utilization Management Auditor jobs in Texas look for? The top searched job categories for Utilization Management Auditor jobs in Texas are:
What cities in Texas are hiring for Utilization Management Auditor jobs? Cities in Texas with the most Utilization Management Auditor job openings:
Utilization Management Auditor jobs near you

UM Nurse

Gonzaba Medical Group

San Antonio, TX • On-site

Full-time

Re-posted 3 days ago

Gonzaba Medical Group rating

5.6

Company rating: 5.6 out of 10

Based on 19 frontline employees who took The Breakroom Quiz

Job description

General Summary: UM Nurse focuses on the Gonzaba Medical Group UM Review Process.
Supervisory Responsibilities: This position has no supervisory responsibilities.
General Requirements: All duties performed will be done accurately and in a timely manner.
  1. Carries out GMG UM Program activities and UM Operations.
  2. Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
  3. Participates in educational programs as needed.
  4. Maintains strict confidentiality practicing HIPAA rules and regulations.
  5. Other duties as assigned.
  6. Bilingual English/ Spanish fluency preferred.
  7. Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
  8. Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.

Essential Job Responsibilities:
  1. Provides clinical perspective/input to Review team, UM team and Referral Specialists.
  2. Summarizes medical records documentation for physician medical necessity review.
  3. Composes Denial letters according to CMS defined standards and according to UM delegation rules.
  4. Applies evidenced-based criteria to medical necessity reviews and documents appropriately in review summary.
  5. Performs daily authorization oversight to insure proper completion of referral documentation in EZ Cap and EMR, timeliness of determinations and compliance with UM Delegation requirements in daily operations.
  6. Pulls, validates, and submits ODAG reports, Part C reports and other UM reports to health plans upon request, meeting submission deadlines.
  7. Successfully performs live ODAG reviews with health plan auditors; successfully responds to "desk review" requests, by submitting screenshots and documents within defined timeline.
  8. Contributes to delegation audits and fulfilling certain requirements for UM delegation related to making UM criteria available to requesting providers upon request, non-contracted providers are consistently identified appropriate State, OIG, MCR opt out screenings are carried out prior to approving the referral service. Ensure use of Board-Certified Specialists in making referral decisions. Other UM requirements for training, monitoring performance measures, etc.
  9. Ensures GMG UM team responds timely to inquiry from claims vendor where an authorization has NOT been obtained previously.
  10. Identifies opportunities for operational improvement, and works collaboratively with UM team, Provider PODS, and other GMG departments.
  11. Communicates effectively regarding UM issues with patients, GMG staff/providers and external staff/providers.
  12. Participates in the annual review of Managed Care, UM policies and procedures, and other periodic reviews as needed.
  13. Promotes the Contracted Network Providers to GMG patients and staff.

Work Environment: Office environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.
Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.
Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.
Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.
Education and Training: Active, unencumbered Registered Nurse with an associate degree or must be state-licensed practical nurse with one year of LVN and clinic experience. Prefer BS in Nursing. Must keep all licenses and certifications current and in good standing as initial and continued employment is contingent up these credentials.
Experience: Requires at least 5 years' experience in Managed Care, and Utilization Management. Experience in a clinic, doctor's office or hospital with a minimum of one-year acute care experience preferred.
Other Requirements: Computer Skills: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.

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