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Utilization Review Management Jobs in Texas (NOW HIRING)

HealthCare Support

Utilization Management

Houston, TX · On-site

$38 - $42/hr

RN Outpatient Utilization Review Remote Texas HealthCare Support is actively seeking multiple ... Communicates concerns that arise in these discussions to the Manager and/or Medical Director.

Acadia Healthcare

Director of Utilization

El Paso, TX · On-site

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

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 ...

Houston Methodist

At Houston Methodist, the Utilization Review Nurse (URN) position is a licensed registered nurse ... This position collaborates with case management in the development and implementation of the plan ...

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Utilization Review Management information

What are the job titles for utilization review management?

Job titles in utilization review management include Utilization Review Nurse, Utilization Review Coordinator, Utilization Review Nurse Case Manager, and Utilization Review Supervisor. These roles typically involve assessing medical necessity, reviewing patient records, and ensuring compliance with healthcare policies, often requiring certification such as the Certified Professional in Healthcare Quality (CPHQ).

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

AspectUtilization Review ManagementUtilization Review Nurse
CredentialsTypically requires a healthcare management or related certification, sometimes a nursing backgroundRegistered Nurse (RN) license, often with additional utilization review certification
Work EnvironmentOffice-based, administrative setting, collaborating with healthcare providers and insurance companiesClinical setting, reviewing patient charts, and making utilization decisions
Employer & IndustryHealth insurance companies, managed care organizations, healthcare administratorsHospitals, insurance companies, healthcare facilities

Utilization Review Management professionals focus on overseeing review processes, policy compliance, and administrative tasks, while Utilization Review Nurses conduct clinical assessments to determine appropriate care. Both roles are essential in healthcare utilization management but differ in responsibilities and work environment.

What are some common challenges faced by professionals in utilization review management, and how can they be addressed?

Professionals in Utilization Review Management often encounter challenges such as balancing regulatory compliance with patient advocacy and managing high caseloads under tight deadlines. Navigating complex insurance policies and ensuring timely communication between healthcare providers and payers can be demanding. Staying organized, leveraging technology for workflow management, and participating in ongoing training can help address these challenges. Additionally, strong collaboration with interdisciplinary teams ensures more effective and efficient utilization review processes.

What is utilization review management?

Utilization Review Management is a process used in healthcare to evaluate the necessity, appropriateness, and efficiency of medical services, procedures, and facilities. Its primary goal is to ensure that patients receive appropriate care while preventing unnecessary or duplicative services. Utilization Review Management helps healthcare providers and insurance companies manage costs, maintain high-quality care, and comply with regulations. Professionals in this field often review patient records, coordinate with clinicians, and make recommendations about coverage or care plans.

What are the key skills and qualifications needed to thrive in utilization review management?

To thrive in Utilization Review Management, you need a solid background in healthcare, strong analytical skills, and often a clinical degree such as RN or LPN, with certification in utilization review or case management being highly beneficial. Familiarity with medical coding systems (ICD-10, CPT), electronic health records (EHRs), and utilization management software is typically required. Excellent communication, critical thinking, and negotiation skills help you collaborate with providers and payers while advocating for patient care. These competencies are vital for ensuring appropriate resource use, regulatory compliance, and optimal patient outcomes.
What cities in Texas are hiring for Utilization Review Management jobs? Cities in Texas with the most Utilization Review Management job openings:
Utilization Review Management jobs near you
Infographic showing various Utilization Review Management job openings in Texas as of August 2026, with employment types broken down into 1% As Needed, 84% Full Time, 13% Part Time, and 2% Contract. Highlights an 92% Physical, 3% Hybrid, and 5% Remote job distribution.

Utilization Review Nurse Health Plans - HP Utilization Management

CHRISTUS Health

Irving, TX • On-site

Other

Re-posted 7 days ago

CHRISTUS Health rating

6.7

Company rating: 6.7 out of 10

Based on 531 frontline employees who took The Breakroom Quiz

531st of 887 rated healthcare providers

Job description

Utilization Review Nurse

The Utilization Review Nurse is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This nurse is responsible for performing a variety of pre-admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (InterQual/MCG/Centers for Medicare and Medicaid Services "CMS" Inpatient List). They effectively and efficiently manage a diverse workload in a fast-paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and guidelines related to UM. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Review Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

Responsibilities:

  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • The prior authorization role completes an assessment of a proposed service to determine if the beneficiary has eligible coverage for the service and if it is medically necessary.
  • Promote quality, cost-effective outcomes through prior authorization and concurrent review of requested services for medical necessity based upon evidence-based clinical guidelines.
  • Identify and present cases of possible quality of care deviations, questionable admissions, and prolonged lengths of stay to the Medical Director for further determination.
  • Appropriately refer beneficiaries who have complex or chronic conditions, a need for transition of care, disease management support, or other identifiable needs for coordination of the beneficiary's member's health care for behavioral health care management.
  • Follow CHRISTUS Health Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent, or detect unauthorized disclosure of Protected Health Information (PHI).
  • Protect the confidentiality of data and intellectual property; assures compliance with national health information guidelines.
  • Analyze clinical information submitted by medical providers to evaluate the medical necessity, appropriateness, and efficiency of the use of medical services, procedures, and facilities.
  • Perform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up.
  • Utilize the nursing process and critical thinking skills to provide oversight of services and evaluation of service options.
  • Ability to work in a variety of settings with culturally diverse communities with the ability to be culturally sensitive and appropriate.
  • Must have excellent communication skills (written and verbal), clinical judgment, initiative, critical thinking, and problem-solving abilities.
  • Must be able to take after hour calls to meet business requirements as needed.

Job Requirements:

Education/Skills

  • Graduate of an accredited school of vocational nursing or equivalent required
  • Associate's (ADN) or Bachelor's (BSN) in Nursing preferred

Experience

  • 3 – 5 years of nursing experience preferred
  • Experience in Microsoft software (e.g., Outlook, Teams, Word, and Excel) required
  • General computer knowledge and capability to use computers required

Licenses, Registrations, or Certifications

  • LVN license in the state of employment or compact required
  • RN license in state of employment or compact preferred

Work Schedule: 5 Days - 8 Hours

Work Type: Full Time

What CHRISTUS Health employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

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About CHRISTUS Health

Sourced by ZipRecruiter

CHRISTUS Health is a prominent name in the healthcare industry, with its headquarters situated in Irving, TX, USA. Established in 1999, the company has since been devoted to providing comprehensive care and extending the healing ministry of Jesus Christ. This not-for-profit health system primarily operates more than 600 healthcare services and programs, including long-term care facilities, health insurance products, community clinics, and outreach services, serving both urban and rural populations.

Industry

Outpatient health care

Company size

1,001 - 5,000 Employees

Headquarters location

Irving, TX, US

Year founded

1999

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