Clinical Reviewer

Nexus Health Systems•Houston, TX

2d•Onsite

About The Position

Nexus Health Systems is seeking an experienced Clinical Reviewer to support the evaluation and admission of patients into our specialized behavioral health, neurodevelopmental, and medically complex programs. The Clinical Reviewer reviews medical records, clinical histories, assessments, and referral documentation to determine clinical appropriateness and program fit. This position develops thorough, high-quality clinical evaluations and summaries that support admission and authorization decisions while meeting the documentation requirements of commercial insurance, Medicaid, and other funding sources. We are specifically seeking an experienced Registered Nurse (RN) or Nurse Practitioner (NP) with strong clinical judgment, excellent documentation skills, and experience evaluating complex patient needs. Nurse Practitioners with clinical leadership experience are strongly encouraged to apply, as this position may offer opportunities for expanded leadership responsibilities within the clinical evaluation team.

Requirements

Registered Nurse: Bachelor's degree in Nursing (BSN) required.
Nurse Practitioner: Master's degree in Nursing or other accredited graduate nursing degree required.
Minimum of 3 years of clinical nursing experience.
Experience in behavioral health, autism spectrum disorder, intellectual/developmental disabilities, pediatrics, or medically complex patient populations preferred.
Previous experience with clinical review, utilization review, care management, admissions evaluations, medical necessity review, or similar clinical decision-making strongly preferred.
Experience preparing clinical documentation for insurance, Medicaid, authorization, or funding approval preferred.
Experience collaborating with interdisciplinary clinical teams.
Leadership, supervisory, or clinical team-lead experience strongly preferred for Nurse Practitioner candidates.
Current, unrestricted Registered Nurse (RN) or Advanced Practice Registered Nurse (APRN)/Nurse Practitioner license.
Current Texas licensure or eligibility to obtain Texas licensure required.
Nurse Practitioner candidates must hold appropriate national board certification applicable to their advanced practice specialty.
Strong clinical judgment and critical-thinking skills.
Excellent written communication and clinical documentation skills.
Ability to interpret complex medical and behavioral health records.
Understanding of clinical risk, medical necessity, and appropriate levels of care.
Strong attention to detail and organizational skills.
Ability to prioritize and manage multiple referrals in a fast-paced environment.
Strong interpersonal and interdisciplinary communication skills.
Professional and compassionate communication with families, clinicians, and referral sources.
Proficiency with electronic medical record (EMR) and CRM systems.
Demonstrated leadership potential and ability to mentor or guide clinical team members.

Nice To Haves

Experience in behavioral health, autism spectrum disorder, intellectual/developmental disabilities, pediatrics, or medically complex patient populations.
Previous experience with clinical review, utilization review, care management, admissions evaluations, medical necessity review, or similar clinical decision-making.
Experience preparing clinical documentation for insurance, Medicaid, authorization, or funding approval.
Leadership, supervisory, or clinical team-lead experience strongly preferred for Nurse Practitioner candidates.
Demonstrated leadership potential and ability to mentor or guide clinical team members.

Responsibilities

Review incoming referrals, medical records, clinical histories, assessments, and supporting documentation to determine clinical appropriateness and program fit.
Evaluate patients with behavioral health conditions, autism spectrum disorder, intellectual and developmental disabilities, and medically complex needs.
Assess patient acuity, clinical risk, medical necessity, and appropriateness for Nexus programs.
Identify missing or insufficient clinical information and obtain additional documentation necessary to complete the evaluation.
Develop clear, comprehensive clinical evaluations and summaries supporting admission and authorization decisions.
Apply sound nursing judgment and critical thinking when evaluating complex referrals.
Prepare clinical documentation that supports medical necessity and meets commercial insurance, Medicaid, and other payer requirements.
Maintain knowledge of payer authorization criteria, documentation standards, regulatory requirements, and evolving funding policies.
Ensure clinical evaluations are accurate, complete, timely, and defensible.
Anticipate potential payer questions or documentation deficiencies and proactively address them during the review process.
Support efficient authorization and admission processes through strong clinical documentation.
Collaborate with referral sources, physicians, nursing teams, admissions staff, clinical leadership, and other interdisciplinary team members.
Communicate with referral sources to clarify clinical information and obtain missing documentation.
Clearly communicate clinical findings, concerns, and recommendations to internal stakeholders.
Interact professionally and compassionately with patients, families, clinicians, and referral partners.
Serve as a clinical resource throughout the referral and evaluation process.
Manage multiple clinical evaluations and referrals simultaneously while maintaining accuracy and attention to detail.
Complete reviews within established turnaround expectations to support timely admission decisions.
Balance speed and responsiveness with patient safety, clinical quality, regulatory compliance, and payer requirements.
Identify opportunities to improve clinical evaluation workflows, documentation quality, and overall efficiency.
Maintain current knowledge of behavioral health conditions, neurodevelopmental disorders, medically complex populations, payer requirements, assessment tools, and evidence-based clinical practices.
Participate in initiatives to improve clinical review, evaluation, and admission processes.
Provide clinical guidance and support to members of the admissions and evaluation teams.
Candidates with appropriate experience may assist with mentoring, clinical oversight, workflow development, and other leadership responsibilities within the evaluation team.
Partner with organizational leadership to strengthen clinical decision-making, documentation quality, and team performance.