Clinical Reviewer, Utilization Management

Job Title

Assists Community First Health Plan (CFHP) members regain optimum health or improved functional capacity by ensuring that members have access to all of the health care services they need in the most efficient and effective manner possible.

Responsibilities include but are not limited to overseeing the allocation of resources, cost and quality of health care for members; coordinating care between the primary care physician, community resources, family and member; coordinating care across the health care continuum while monitoring and managing benefit utilization; and, collaborating with multi-disciplinary health care team members in identifying the educational and discharge needs of members.

Education/

Experience:

Registered Nurse (RN) is required. Bachelor of Science in Nursing (BSN) or Master's degree is preferred. Minimum three (3) years nursing, acute care, quality management or managed care experience is required. Basic knowledge of Medicaid, Medicare, community resources and alternate funding programs is desired. Knowledge of Inter Qual screening criteria as well as DRG, ICD and CPT coding is preferred.

Licensure/Certification:
Current licensure as a Registered Nurse with the Texas State Board of Nurse Examiners is required. Current certification from an appropriate professional agency, such as Case Management Society, is preferred.