Utilization Review Nurse - RN (WHWC)

Role Overview & Responsibilities 

Position Summary

The Utilization Review Nurse is a vital member of the care coordination team, responsible for reviewing patient records, assessing the necessity and appropriateness of proposed treatments, collaborating with healthcare providers, and facilitating communication across multidisciplinary teams to ensure continuity of care. This role requires strong clinical knowledge, excellent communication and organizational skills, and the ability to manage multiple referrals in a fast-paced environment.

Scope and Impact

• Supports care coordination across MHM clinics and contracted specialty providers.
• Influences patient access, quality of care, and timeliness of services through referral review, pre-authorization, and diagnostic coordination.
• May manage a high-volume caseload of concurrent referrals and authorizations.

Decision-Making Authority

• Exercises independent clinical judgment to determine medical necessity and level of care based on referral criteria and documentation.
• Escalates complex cases and exceptions per policy and collaborates with providers for final clinical decisions.

Interactions / Working Relationships

• Daily coordination with primary care providers, contracted specialty providers, and physician office staff.
• Regular collaboration with Care Coordination RN/LVN/MA, social services, and multidisciplinary teams.
• Frequent communication with Patient Referral Coordinators regarding orders, pre-authorizations, scheduling, and follow-up.

Essential Duties and Responsibilities

• Review incoming clinical documentation and referral requests to determine medical necessity and appropriate level of care. (25%)
• Enter, update, and maintain accurate clinical information in medical management and EHR systems. (10%)
• Process requests and authorizations within required timelines and payer or organizational guidelines. (15%)
• Coordinate and transmit diagnostic orders to Patient Referral Coordinators for labs, imaging, and procedures at MHS facilities. (10%)
• Prepare and submit pre-authorization requests on behalf of contracted specialty providers for services and medications. (10%)
• Communicate effectively with MHM clinics and specialty offices regarding acceptance, scheduling, and follow-up care. (10%)
• Collaborate with multidisciplinary teams to support the care model and patient-centered medical home principles. (10%)
• Educate patients and families regarding care plans, diagnostics, and next steps as appropriate. (5%)
• Document tracked outcomes using appropriate terminology and standard abbreviations; maintain accurate referral records. (3%)
• Adhere to HIPAA, apply medical terminology accurately, and perform other duties as assigned. (2%)

Supervisory or Leadership Responsibilities

This position does not supervise others.Qualifications

Minimum Qualifications (Required) 

• Education: Graduation from an accredited nursing program.
• Licenses/Certifications: Active Registered Nurse (RN) licensure in the state of Texas.
• Experience: Minimum of three years of nursing experience.
• Other Required Skills/Knowledge: 
• Strong knowledge of medical terminology and HIPAA compliance
• Effective multitasking, time management, and professional phone etiquette
• Excellent organizational skills with attention to clinical detail
• Ability to work independently and as part of a team in a fast-paced environment

Preferred Qualifications

• Bachelor of Science in Nursing (BSN)
• Experience in case management, care coordination, or an acute hospital setting
• Spanish proficiency
• Experience working with multidisciplinary teams, referral management, and payer pre-authorizations

Knowledge, Skills, and Abilities (KSAs)

• Communication and collaboration with providers, staff, and patients
• Critical thinking, clinical judgment, and problem-solving
• Customer service and patient experience focus, modeling AIDET principles
• Organization, prioritization, and accuracy in documentation
• Proficiency with medical terminology and referral workflows

Language Skills

• Required: English
• Preferred: Spanish

Technology and Tools

• Required/Preferred: 
• Electronic Health Records (EHR) and medical management systems
• Outlook, Word, Excel, PowerPoint
• Internet-based faxing systems such as Sfax
• Patient management software

Work Environment and Physical Demands

• Typical setting: Office environment with potential direct patient interaction; may involve hybrid clinic support.
• Travel: Occasional local travel may be required. Must maintain valid driver’s license and auto liability insurance.
• Physical requirements: Bending, stooping, twisting, turning, walking, climbing step stools, sitting and standing for periods of time. Must be able to lift and maneuver up to 25 pounds.

1. Disclaimer Clause

This job description is not intended to be all-inclusive. Team members may perform other related duties as assigned to meet the ongoing needs of the organization. Methodist Healthcare Ministries reserves the right to revise or change job duties and responsibilities as the need arises.

2. Equal Employment Opportunity (EEO) Statement

Methodist Healthcare Ministries is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All employment decisions are made without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, or genetic information.

3. At-Will Employment Statement

Employment with Methodist Healthcare Ministries is at-will and may be terminated by either the employee or the organization at any time, with or without cause or notice. Nothing in this job description constitutes a contract of employment or a guarantee of continued employment.

4. Americans with Disabilities Act (ADA) Statement

Methodist Healthcare Ministries is committed to complying with the Americans with Disabilities Act (ADA) and ensuring equal opportunity in employment for qualified individuals with disabilities. Reasonable accommodation may be provided to enable qualified individuals with disabilities to perform the essential functions of this job. Requests for accommodation will be reviewed on a case-by-case basis in accordance with applicable law.

Employee Acknowledgement

I acknowledge that I have read and received a copy of this job description and understand this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.