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Utilization Review Director Jobs in Texas (NOW HIRING)

Acadia Healthcare

Director of Utilization

El Paso, TX · On-site

Direct and manage the day-to-day operations of the Utilization Review department. Responsibilities ESSENTIAL FUNCTIONS: * Monitor utilization of services and optimize reimbursement for the facility ...

HealthCare Support

Utilization Management

Houston, TX · On-site

$38 - $42/hr

RN Outpatient Utilization Review Remote Texas HealthCare Support is actively seeking multiple ... Refers cases that do not meet criteria to Medical Director for review. * Assists in discharge ...

Houston Methodist

At Houston Methodist, the Utilization Review Nurse (URN) position is a licensed registered nurse ... Reviews H&Ps and admitting orders of all direct, transfer, and emergency care patients designated ...

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Utilization Review Director information

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How much do utilization review director jobs pay per hour?

As of Sep 1, 2026, the average hourly pay for utilization review director in Texas is $39.39, according to ZipRecruiter salary data. Most workers in this role earn between $31.15 and $45.24 per hour, depending on experience, location, and employer.

What does a utilization review director do?

A Utilization Review Director oversees the evaluation of medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They lead teams that review patient care requests, manage compliance with regulations, and implement strategies to ensure cost-effective care without compromising quality. Their responsibilities often include policy development, data analysis, and collaboration with healthcare providers to optimize resource use and improve patient outcomes.

What are the key skills and qualifications needed to thrive as a utilization review director, and why are they important?

To thrive as a Utilization Review Director, you need a deep understanding of clinical guidelines, healthcare regulations, and case management principles, typically supported by a nursing or related healthcare degree and relevant licensure. Familiarity with utilization management software, electronic health records (EHR), and certifications such as Certified Case Manager (CCM) or Accredited Case Manager (ACM) is common in the field. Strong leadership, communication, analytical thinking, and decision-making skills help you effectively manage teams and ensure compliance. These competencies ensure efficient resource use, regulatory adherence, and high-quality patient outcomes within healthcare organizations.

What are some common challenges faced by a utilization review director, and how can they be addressed?

A Utilization Review Director often navigates challenges such as balancing regulatory compliance with organizational goals, managing interdisciplinary teams, and keeping up with evolving healthcare policies. Staying proactive with ongoing education, fostering open communication among staff, and implementing efficient review processes can help address these issues. Additionally, leveraging data analytics and technology streamlines case reviews and ensures evidence-based decision-making, ultimately improving both patient outcomes and operational efficiency.

What is the difference between Utilization Review Director vs Utilization Review Nurse?

AspectUtilization Review DirectorUtilization Review Nurse
CredentialsRN license, management experience, certifications (e.g., CCM)RN license, certification in case management or utilization review (e.g., CUC)
Work EnvironmentAdministrative, leadership roles overseeing teamsClinical, review of patient cases, direct patient care
Employer & IndustryHospitals, insurance companies, healthcare organizationsHospitals, insurance companies, healthcare providers
Search & Comparison IntentLeadership, management, strategic planning in utilization reviewClinical review, case assessment, patient care coordination

The Utilization Review Director typically oversees review teams and manages utilization strategies, requiring leadership skills and management experience. In contrast, the Utilization Review Nurse focuses on clinical case assessments and patient care reviews. Both roles require RN licensure and relevant certifications but differ mainly in scope and responsibilities.

What are the most commonly searched types of Utilization Review jobs in Texas?

The most popular types of Utilization Review jobs in Texas are:

What cities in Texas are hiring for Utilization Review Director jobs?

Cities in Texas with the most Utilization Review Director job openings:

Utilization Review Director jobs near you

RN Utilization Review Coordinator, Full-time

Surgery Partners

Addison, TX • On-site

Full-time

Re-posted 24 days ago

Surgery Partners rating

7.7

Company rating: 7.7 out of 10

Based on 85 frontline employees who took The Breakroom Quiz

166th of 898 rated healthcare providers

Job description

Hiring Now for RN Utilization Review Coordinator
Department: Case Management
Shift: Full-time Hybrid
Job Summary:
The RN Case Manager/Utilization Review is responsible for performing prospective, concurrent, and post-discharge utilization reviews to ensure appropriate patient status, medical necessity, and compliance with hospital policy, payer requirements, and applicable local, state and federal regulations, including Centers for Medicare & Medicaid Services (CMS) guidelines. The role supports accurate admission status determinations, active denial management, and collaboration with physicians, case managers, and interdisciplinary team members to promote efficient patient progression through the episode of care. This position also assists with discharge planning activities and contributes to quarterly and annual utilization review reporting and performance improvement initiatives.
Utilization Review and Medical Necessity
  1. Conduct comprehensive medical record reviews using specific criteria and guidelines as approved and/or established by medical staff, CMS, and other state and federal agencies while ensuring physician and nurse documentation meets set standards.
  2. Perform prospective (pre-admission and pre-operative), concurrent, and post-discharge utilization reviews to verify medical necessity and appropriate level of care throughout the episode of care using the hospital-approved criteria software.
  3. Screen and determine appropriate admission status (inpatient, observation, outpatient, or outpatient in a bed) based on clinical documentation, hospital-approved medical-necessity guidelines, and payer requirements.
  4. Facilitate appropriate admission status determinations based on clinical documentation and payer requirements.
  5. Review clinical documentation for accuracy, completeness, and compliance with regulatory and payer standards.
  6. Collaborate with physicians and nursing staff to ensure timely, accurate orders and documentation supporting medical necessity.
  7. Communicate with physicians when cases do not meet admission or continued stay criteria and assist with resolution.
  8. Submit timely admission, continued stay, and discharge notification and appropriate clinicals to insurance companies as required.
  9. Complete admission status changes as needed in the hospital computer system.

Denial Management:
  1. Identify, track, and manage utilization review denials related to admission status, level of care, length of stay, and medical necessity.
  2. Draft, write, and submit denial appeal letters using clinical judgment, medical record review, applicable payer, CMS, and regulatory guidelines to support medical necessity determinations.
  3. Collaborate with physicians, case managers, physician advisors, and leadership to obtain supporting clinical documentation, physician statements, and peer-to-peer review input for appeals to support denial resolution.
  4. Monitor denial outcomes, appeal success rates, and payer trends; analyze root causes and provide feedback, education, and recommendations to reduce future denials.
  5. Maintain accurate documentation of denials and appeals in accordance with hospital policy and regulatory requirements.

Discharge Planning Support
  1. When needed, collaborate with the Case Management team to support timely and safe discharge planning.
  2. Serve as the patient advocates and enhances collaborative relationships with the healthcare team, physicians, patients, and families to maximize the patient's and family's ability to make informed healthcare decisions.
  3. When needed, assist in identifying and addressing barriers to discharge, including durable medical equipment (DME), home health services, medications, and therapy need.
  4. Reinforce patient and family education to promote successful transitions of care.
  5. When needed, transmit Continuity of Care Documents to appropriate post-acute providers to ensure follow-up care.

Reporting, Compliance & Quality
  1. Monitor, track, and analyze avoidable days and extended lengths of stay; identify contributing factors related to utilization, payer processes, discharge barriers, and system delays, and collaborate with Case Management, physicians, and interdisciplinary teams to support timely resolution.
  2. Assist the Case Management Manager and Quality Director with data collection and analysis for quarterly and annual utilization review reports.
  3. Participate in regulatory audits, surveys, and internal reviews related to utilization management.
  4. Investigate and report adverse occurrences and trends related to utilization, discharge planning, or resource management.
  5. Provide staff education related to utilization review processes, medical necessity, and resource utilization.

Professional Responsibilities:
Must demonstrate high attention to detail, the ability to multi-task, prioritize, and have strong critical thinking skills to address issues that arise unexpectedly.
  1. Must encompass the skill to follow through with tasks and situations while providing clear communication to others throughout the process.
  2. Maintain a high standard of professionalism and ethical conduct in accordance with hospital policies and the Methodist Hospital for Surgery Code of Conduct.
  3. Support and facilitate initiatives enhancing patient outcomes, patient satisfaction, and regulatory compliance.
  4. Communicate effectively, professionally, accurately, and timely with all staff and patients.
  5. Demonstrates the spirit of philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment
  6. Perform other duties as assigned or required.

Minimum Requirements:
Education: Bachelor of Science in Nursing preferred.
Certification, Licensure: Active RN license in Texas; current CPR certification. Case Management Certification(s) preferred.
Experience, Training, Knowledge: At least five years of experience with Case Management, Discharge Planning, and Utilization Review.
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.

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