Utilization Review Rn Jobs in Houston, TX (NOW HIRING)

Help patients access the right level of care while driving exceptional clinical outcomes.

Nexus Health Systems is seeking an experienced and detail-oriented RN Care Coordinator – Admissions to support the clinical referral evaluation process across our continuum of care. This role serves as a key clinical resource within the Admissions Department, partnering closely with Clinical Liaisons, Utilization Review, Admissions, and operational leadership to ensure appropriate patient placement and timely referral review.

Reporting directly to the Director of Admissions, the RN Care Coordinator is responsible for evaluating referrals, developing clinical summaries, supporting authorization strategies, and providing clinical insight that drives informed admission decisions. This position plays a vital role in ensuring patients are matched to the appropriate level of care while supporting organizational growth and payer compliance.

The RN Care Coordinator supports the coordination of clinical objectives for patient referrals while maintaining financial and clinical accountability for Nexus Health Systems referral protocols. This role works collaboratively with both clinical and non-clinical departments to evaluate referrals, optimize payer outcomes, support admission decisions, and contribute to departmental performance objectives.

The ideal candidate is an experienced Registered Nurse with strong clinical assessment skills, knowledge of payer requirements, and the ability to communicate effectively with referral sources, physicians, and interdisciplinary teams.

• Evaluate incoming patient referrals and identify appropriate clinical programming and level of care.
• Develop comprehensive clinical summaries to support admission recommendations.
• Review medical records, physician documentation, therapy evaluations, and supporting clinical information.
• Participate in clinical case reviews and live payer reviews as needed.
• Collaborate with Clinical Liaisons to support referral conversion and admission decisions.
• Maintain referral documentation and correspondence within centralized referral tracking systems.
• Identify clinical trends and patterns that may impact referral outcomes and provide recommendations for resolution.

• Support referral evaluation processes and identify opportunities to reduce denials and appeals.
• Assist with denial management efforts and identify root causes of authorization denials.
• Participate in appeals and peer-to-peer reviews involving clinical justification and documentation.
• Research and remain current on Medicare, Medicaid, and Commercial Payer regulations and updates.
• Provide clinical guidance to support payer authorization strategies and reimbursement optimization.
• Assist in identifying barriers impacting referral aging, denials, and write-offs.

• Ensure compliance with all applicable federal, state, payer, and accreditation requirements.
• Participate in quality assurance audits and departmental process improvement initiatives.
• Monitor referral workflows and recommend operational improvements supported by data.
• Support correspondence review processes and ensure appropriate action is taken within established timelines.
• Assist with departmental reporting and distribution of key performance metrics.
• Support achievement of departmental goals and performance indicators.

• Serve as a clinical resource to Admissions, Clinical Liaisons, Utilization Review, and operational leaders.
• Communicate effectively with referral sources, providers, payers, and internal stakeholders.
• Provide exceptional customer service while maintaining professionalism and urgency.
• Participate in departmental meetings and serve as a subject matter expert when appropriate.
• Escalate complex clinical or operational concerns to leadership as needed.

• Associate Degree in Nursing (ADN) required.
• Bachelor of Science in Nursing (BSN) preferred.

• Minimum two (2) years of healthcare experience in a clinical review, utilization management, admissions, case management, or care coordination setting.
• Experience evaluating medical necessity, payer requirements, and authorization processes preferred.
• Experience in rehabilitation, behavioral health, long-term acute care, post-acute care, or hospital-based admissions strongly preferred.

• Current Registered Nurse (RN) license in good standing.

• Strong clinical assessment and critical thinking skills.
• Knowledge of Medicare, Medicaid, and commercial payer requirements.
• Ability to interpret medical records and clinical documentation.
• Strong written communication skills with experience developing clinical summaries and evaluations.
• Excellent organizational and time management abilities.
• Proficiency with electronic medical records and referral management systems.
• Ability to manage multiple priorities in a fast-paced environment.
• Strong interpersonal skills and ability to collaborate across departments.

At Nexus Health Systems, our mission is to provide exceptional care to patients with complex medical, neurological, behavioral, and rehabilitation needs. As an RN Care Coordinator, you will play a critical role in ensuring patients are connected to the most appropriate services while supporting organizational growth and clinical excellence.

Join a team committed to innovation, collaboration, and improving lives every day.