Utilization Review Care Coordinator (RN)

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