Utilization Review Care Coordinator (RN)

Job Description

Job Description

Utilization Review Care Coordinator (RN)

Location: San Antonio, TX

Pay Rate: Starting at $29.00/hour

Schedule: Monday-Friday | 8:00 AM-5:00 PM

Dean's Professional Services is seeking an experienced and detail-oriented Utilization Review Care Coordinator (RN) to support a leading healthcare organization in San Antonio, TX .

This is an excellent opportunity for an experienced Registered Nurse with a strong background in utilization review, care management, and clinical documentation . The ideal candidate will have strong clinical judgment, analytical skills, and the ability to collaborate with healthcare providers and payers to ensure patients receive appropriate, timely, and cost-effective care.

Responsibilities

• Conduct utilization reviews to assess the medical necessity, appropriateness, and efficiency of healthcare services.

   

• Review patient medical records, treatment plans, and clinical documentation to ensure services meet established clinical guidelines and regulatory requirements.

   

• Evaluate patient cases and identify opportunities to improve care delivery and appropriate resource utilization.

   

• Collaborate with physicians, nurses, case managers, and other healthcare professionals regarding patient care and utilization concerns.

   

• Facilitate authorization processes for hospital admissions, treatments, procedures, and other healthcare services with insurance companies and payers.

   

• Monitor patient progress and discharge plans to support timely and appropriate transitions of care.

   

• Identify potential barriers to discharge and communicate concerns to the appropriate members of the care team.

   

• Educate patients, families, and healthcare providers regarding utilization review processes, requirements, and available resources.

   

• Maintain accurate and timely documentation of utilization reviews, clinical findings, authorizations, and actions taken.

   

• Participate in interdisciplinary care management and utilization review meetings.

   

• Apply established utilization management criteria and organizational policies when reviewing cases.

   

• Ensure utilization review activities comply with applicable healthcare regulations, including Medicare and Medicaid guidelines .

   

• Stay current with utilization review, care management, regulatory, and healthcare industry standards.

   

• Handle multiple priorities and complex cases while maintaining accuracy, confidentiality, and strong patient advocacy.

   

• Perform other duties as assigned.

   

Qualifications

• Bachelor's degree from an accredited school of Nursing required.

   

• Minimum 3 years of clinical nursing experience required.

   

• Minimum 2 years of utilization review experience required.

   

• Current Texas RN license or Compact RN license required.

   

• Texas Board of Nursing RN license required upon hire.

   

• InterQual experience preferred.

   

• ACM (Accredited Case Manager) or CCM (Certified Case Manager) certification preferred.

   

• CPR certification required within 7 days of hire.

   

• Strong knowledge of utilization review processes, clinical guidelines, and regulatory requirements.

   

• Knowledge of medical terminology, disease processes, treatment protocols, and healthcare delivery systems.

   

• Understanding of insurance requirements and payer authorization processes.

   

• Knowledge of Medicare and Medicaid utilization and regulatory guidelines.

   

• Proficiency in reviewing and interpreting medical records and clinical documentation.

   

• Strong analytical, critical-thinking, and decision-making ski