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Utilization Review Np Jobs in Texas (NOW HIRING)

Shannon Health

Utilization Review Nurse

Big Spring, TX · On-site

Job Summary The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the ...

Shannon Health

Utilization Review Nurse

Big Spring, TX · On-site

Job Summary The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the ...

Bracane Co

Utilization Review Nurse

Plano, TX · Remote

Austin area - Travis/Williamson Counties or Richardson area - Dallas/Collin Counties*** RN working ... This position is responsible for performing initial, concurrent review activities; discharge care ...

Medix

Utilization Review Nurse

Fort Worth, TX · On-site

$38.46 - $43.27/hr

Job Summary Our client is seeking a skilled Utilization Review Nurse to join their team. This role involves analyzing billing data, documenting work, and adhering to HIPAA regulations. The successful ...

Moffitt

$77K - $117K/yr

Summary The Utilization Review Nurse is responsible for performing initial, concurrent, and retrospective utilization reviews to determine medical necessity, appropriate level of care, and continued ...

Evry Healthcare Inc.

Utilization Review Nurse (RN)

Dallas, TX · On-site

$80 - $100/hr

The RN Integrated Care Coordinator (UM) provides comprehensive care coordination services and is ... Rotating weekend hours are required to address utilization review cases. Roles and Responsibilities

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Utilization Review Np information

What does a utilization review nurse practitioner do?

A Utilization Review Nurse Practitioner (NP) evaluates the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They review patient records, treatment plans, and insurance coverage to ensure that care meets established guidelines and regulatory requirements. Utilization Review NPs help coordinate care, prevent unnecessary procedures, and support cost-effective healthcare delivery while ensuring patient safety and quality outcomes.

What are some common challenges utilization review nurse practitioners face when collaborating with healthcare providers and insurance companies?

Utilization Review Nurse Practitioners often navigate the challenge of balancing patient advocacy with payer requirements. They must effectively communicate clinical justifications to both healthcare providers and insurance representatives, sometimes mediating disagreements over the necessity of certain treatments or hospital stays. Staying up-to-date with ever-changing insurance guidelines and ensuring timely documentation can also be demanding, but strong organizational and interpersonal skills help facilitate smooth collaboration and successful patient outcomes.

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

To thrive as a Utilization Review Nurse Practitioner (NP), you need expert clinical judgment, a strong understanding of healthcare regulations, and advanced assessment skills, typically supported by an active NP license and clinical experience. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of insurance guidelines such as Medicare and Medicaid are commonly required. Excellent communication, attention to detail, and critical thinking are vital soft skills for effective case evaluations and collaboration with providers. These competencies ensure accurate, efficient reviews that support quality care, compliance, and cost-effective treatment decisions.

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

AspectUtilization Review NpUtilization Review Nurse
CredentialsMaster's degree in Nursing, Nurse Practitioner certification, state licensureRegistered Nurse (RN) license, possibly with certification in utilization review
Work EnvironmentHealthcare facilities, insurance companies, utilization review organizationsHospitals, insurance companies, outpatient clinics
Job ResponsibilitiesAssess medical necessity, authorize treatments, make clinical decisions, often with greater autonomyReview medical records, support authorization processes, follow established guidelines

Utilization Review NPs typically have advanced clinical training and greater decision-making authority compared to Utilization Review Nurses. Both roles focus on evaluating medical necessity, but NPs often perform more complex assessments and can make independent recommendations, whereas nurses support the review process under supervision or guidelines.

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Utilization Review Np jobs near you
Infographic showing various Utilization Review Np job openings in Texas as of August 2026, with employment types broken down into 1% As Needed, 80% Full Time, 15% Part Time, 1% Temporary, and 3% Contract. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution.

Utilization Review Nurse

Shannon Health

Big Spring, TX • On-site

Full-time

Re-posted 14 days ago

Job description

Job Summary
The Utilization Review (UR) Nurse has acute knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. There will be interaction with providers, patient, and the care team for continued UM process. Further job duties will include Denial prevention, denial management, Implementation of process improvements to mitigate payer denials & improve front-end processes, Collaboration with internal Physician Advisor and external physician advisors regarding physician practices (particularly documentation deficiencies/admission practices). This individual identifies, develops, and provides orientation, and training, for appropriate staff and colleagues on an ongoing basis. He/she actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. This individual maintains current and accurate knowledge regarding commercial and government payers and CIHQ regulations/guidelines/criteria related to UM. The UR Nurse effectively and efficiently manages a diverse workload in a dynamic regulatory environment. The UR Nurse is a member of, and provides support to, the hospital's UR Committee. He/she collaborates with multiple leaders at various levels throughout Shannon Health, for the purpose of supporting and improving the UM program.
Qualifications
Education
  • Required
    • High School Diploma, GED, or equivalent
    • Associate's degree in Nursing
  • Preferred
    • Bachelor's degree in Nursing

Experience:
  • Required
    • Five years of experience in Clinical Nursing
  • Preferred
    • Three years of experience in Inpatient Utilization Review

Certification/Licensure:
  • Required
    • Registered Nurse (RN), with authorization to practice in the State of Texas
  • Preferred
    • Accredited Case Manager (ACM) through ACMA
    • Certified Case Manager (CCM) through CCMC

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