Utilization Review Nurse - RN (DHWC)

Methodist Healthcare Ministries of S. Tx•San Antonio, TX

5d•$74,246 - $94,664•Hybrid

About The Position

The Utilization Review Nurse (RN) supports care coordination by reviewing clinical documentation, evaluating medical necessity, and facilitating communication between providers and care teams to ensure appropriate, timely, and patient-centered care. This role impacts patient outcomes across the care continuum by ensuring appropriate utilization of healthcare services, supporting referral processes, and promoting adherence to care coordination and patient-centered medical home principles. The role exercises clinical judgment in reviewing patient records, determining appropriateness of care, and identifying next steps within established guidelines and protocols. Complex cases are escalated as needed. The position involves frequent communication with clinics and external partners to coordinate patient care and referrals.

Requirements

Graduate of an accredited nursing program
Active Registered Nurse (RN) license in the State of Texas
Minimum of three (3) years of RN experience
Strong clinical assessment and critical thinking skills
Effective communication and interpersonal skills
Ability to multitask and manage multiple referrals simultaneously
Strong organizational skills and attention to detail
Knowledge of medical terminology and clinical documentation standards
Ability to work independently and collaboratively in a fast-paced environment
English proficiency
Valid driver's license and insurance required

Nice To Haves

Bachelor of Science in Nursing (BSN)
Experience in case management, care coordination, or acute care settings
Bilingual (English/Spanish) proficiency
Spanish proficiency

Responsibilities

Review patient records, referral notes, and treatment plans to determine medical necessity and appropriate level of care
Coordinate with specialty providers and internal teams to ensure continuity of care and timely processing of referrals
Enter, maintain, and document clinical information in electronic health record (EHR) and medical management systems
Process pre-authorizations and diagnostic orders in collaboration with Patient Referral Coordinators
Communicate patient status updates, appointment scheduling, and follow-up care with clinics and providers
Provide patient and family education regarding conditions, treatments, and care plans
Ensure compliance with HIPAA regulations and organizational policies
Promote patient-centered medical home principles and support care coordination initiatives
Participate in multidisciplinary collaboration and case consultation
Perform additional duties as assigned