St. David's North Austin Medical CenterNewRN Clinical Reviewer Maternal St. David's North Austin Medical CenterRN Clinical Reviewer MaternalAustin, TXThe hospital also features the Texas Institute for Robotic Surgery, bariatric (weight loss) surgery, a Heart and Vascular Center, neurology and neurosurgery, a kidney transplant program, a Level IV Epilepsy Center, as well as inpatient and outpatient surgery and acute rehabilitation services for both inpatients and outpatients. As a full partner of the healthcare team, the SDHRN Clinical Reviewer collaborates with all other healthcare disciplines to achieve successful execution of the of the results of the quality metrics determined by the Maternal QAPI Committee oversight.
CornerStone StaffingNewPharmacy Technician CornerStone StaffingPharmacy TechnicianThe Colony, TXThe Pharmacy Technician supports clinical pharmacy programs by coordinating medication-related tasks and helping members navigate prescription and lifestyle resources. • Guide members through lifestyle vendor programs, resolve questions or issues, and act as a liaison between members, vendors, and clinical reviewers.
University Medical Center of El PasoUtilization Rev Nurse Coord , El Paso Health University Medical Center of El PasoUtilization Rev Nurse Coord , El Paso HealthEl Paso, TXStrong knowledge of utilization review in Medicaid HMO required, with working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement required. Ensures the Utilization Reviewers conduct a thorough and efficient review of each admission and continued stay while providing high quality health care in a cost effective manner.
HCA HealthcareRN Clinical Reviewer Maternal HCA HealthcareRN Clinical Reviewer MaternalAustin, TXThe hospital also features the Texas Institute for Robotic Surgery, bariatric (weight loss) surgery, a Heart and Vascular Center, neurology and neurosurgery, a kidney transplant program, a Level IV Epilepsy Center, as well as inpatient and outpatient surgery and acute rehabilitation services for both inpatients and outpatients. As a full partner of the healthcare team, the SDHRN Clinical Reviewer collaborates with all other healthcare disciplines to achieve successful execution of the of the results of the quality metrics determined by the Maternal QAPI Committee oversight.
CVS Health CorpPrior Authorization Clinical Reviewer CVS Health CorpPrior Authorization Clinical ReviewerTX$26.01–$74.78 / yearApplication of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
TriWest Healthcare AllianceUtilization Clinical Reviewer TriWest Healthcare AllianceUtilization Clinical ReviewerAustin, TXRemoteFull timeApplies clinical knowledge to make determinations for preauthorization, inpatient and continued stay reviews for Behavioral Health and Medical/Surgical requests to establish medical necessity, benefit coverage, appropriateness of quality of care, and length of stay or care plan. The Utilization Management Clinical Review nurse reviews and makes decisions about the appropriateness and level of beneficiary care being provided in an effort to provide cost effective care and ensure proper utilization of resources.
TriWest Healthcare AllianceClinical Quality Reviewer TriWest Healthcare AllianceClinical Quality ReviewerAustin, TXRemoteFull timeo Bachelor's in Nursing or Certified Professional in Healthcare Quality (CPHQ) o 1 or more years team lead or supervisory experience o 1 year experience in Quality Management o 1 year experience with data analysis and reporting o Experience with InterQual or similar criteria sets o General knowledge of Medicare, Veterans Administration, or other government health care programs. Technical Skills: General knowledge of Medicare, Veterans Administration, or other government health care programs; knowledge in the application of clinical criteria: InterQual, Milliman, PAS-LOS, ICD-9-CM, DSM, CPT-4, and HCPCs; Proficient with Microsoft Word and Excel.
Dane StreetBoard Certified Physician Reviewer - Orthopedic Surgeon (TX) Dane StreetBoard Certified Physician Reviewer - Orthopedic Surgeon (TX)TXBenefits Independent consultant role offering schedule flexibility and predictable work hours Ability to select case types and workload based on your availability No doctor-patient relationship established; no treatment is provided - all reviews are advisory only Streamlined case flow through a user-friendly online work portal Dane Street manages all administrative processes, medical record organization, and communications Fully prepared cases with organized medical records and applicable clinical guidelines Initial training provided, with ongoing support and a dedicated point of contact. Requirements MD or DO with completion of an accredited Orthopedic Surgery residency Board Certification in Orthopedic Surgery Current, unrestricted Texas medical license Minimum of 5+ years of clinical orthopedic experience Ability to attend all required orientation and training sessions Maintains appropriate credentialing, state licensure, and any certifications required to perform the role.
Bienvivir All Inclusive HealthMedical Records Reviewer Bienvivir All Inclusive HealthMedical Records ReviewerEl Paso$13.42–$20.13Retrieves records from the EMR, prepares and audits medical record packets for participants placement admissions, respite stays, and monthly medical records updates to be sent to nursing home facilities and maintains records of the packets sent as a backup documentation. Bienvivir All-Inclusive Senior Health (“Bienvivir”) is a community-based, patient-centered, comprehensive health care delivery system that advocates and promotes quality of life, optimum independence, dignity, and choices in a nurturing environment for frail seniors.
Integrated Resources, IncPhysician Reviewer Integrated Resources, IncPhysician ReviewerRichardson, TXor D.O, unrestricted and active license to practice medicine requested and 5 years clinical experience to include inpatient experience, or any combination of education/experience that would provide an equivalent background. Identifies opportunities to manage members' clinical situations with a view toward creative problem solving and anticipation of possible future clinical problems for the member.
MMSNewCardiology Medical Reviewer (Project-Based) - Remote MMSCardiology Medical Reviewer (Project-Based) - RemoteAustin, TXRemotePart timeWith a global footprint across four continents, MMS not only maintains an industry-leading customer satisfaction rating but also fosters a collaborative and inclusive work environment where employees can thrive. Responsible for strategies in pre and post marketing risk management, as well as keeping abreast of pharmacovigilance methods and trends in published literature and global regulations.
TriWest Healthcare AllianceClaims Reviewer TriWest Healthcare AllianceClaims ReviewerAustin, TXRemoteFull timeProficient with claim and coding tools and resources, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management, and/or the Claims Subcontractor as needed.
Zelis Healthcare, Inc.Inpatient DRG Reviewer Zelis Healthcare, Inc.Inpatient DRG ReviewerPlano, TX$79,000–$99,750 / yearRN or LVN required • Inpatient Coding Certification required (CCS, CIC) within 4 - 6 months of hire date • 1 -3 years reviewing and or auditing ICD-10 CM, MS-DRG and APPR-DRG claims preferred • Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs • Experience performing readmission reviews, including evaluating relatedness, preventability, and compliance with readmission policies • Understanding of hospital coding and billing rules • Clinical skills to evaluate appropriate Medical Record Coding • Experience conducting root cause analysis and identifying solutions • Strong organization skills with attention to detail • Outstanding verbal and written communication skills. • Using the revised codes, regroup the claim using provided software to determine the 'new DRG' • Where the regrouped 'new DRG' differs from what was originally claimed by the provider, write a customer facing 'rationale' or 'findings' statement, highlighting the problems found and justifying the revised choices of new codes and DRG, based on the clinical evidence obtained during the review • Document all aspects of audits including uploading all provider communications, clinical rationale, and/or financial research • Identify new DRG coding concepts to expand the DRG product.
Zelis Healthcare, Inc.Inpatient DRG Sr. Reviewer Zelis Healthcare, Inc.Inpatient DRG Sr. ReviewerPlano, TX$95,000–$120,650 / yearWhat You'll Bring to Zelis: Registered Nurse licensure preferred Inpatient Coding Certification required (i.e., CCS, CIC, RHIA, RHIT) 5+ years reviewing and/or auditing ICD-10 CM, MS-DRG, and APR-DRG claims preferred Solid understanding of audit techniques, identification of revenue opportunities, and financial negotiation with providers Experience and working knowledge of Health Insurance, Medicare guidelines, and various healthcare programs Strong understanding of hospital coding and billing rules Clinical and critical thinking skills to evaluate appropriate coding Strong organization skills with attention to detail Excellent communication skills both verbal and written, and skilled at developing and maintaining effective working relationships Demonstrated thought leadership and motivation skills, a self-starter with an ability to research and resolve issues. As part of the Price Optimization division, this role is responsible for conducting post-service, pre-payment and post pay comprehensive inpatient DRG Quality Assurance reviews in an effort to increase the savings achieved for Zelis clients.
MindlancePhysician Reviewer MindlancePhysician ReviewerRichardson, TXor D.O, unrestricted and active license to practice medicine requested and 5 years clinical experience to include inpatient experience, or any combination of education/experience that would provide an equivalent background. Identifies opportunities to manage members' clinical situations with a view toward creative problem solving and anticipation of possible future clinical problems for the member.
TriWest Healthcare AllianceSr Claims Reviewer TriWest Healthcare AllianceSr Claims ReviewerAustin, TXRemoteFull timeProficient with claim and coding tools such as Supercoder, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. This role will serve as a SME and will collaborate with Claims leadership, Training, the Claims Content Specialist, and internal business partners to ensure procedures and training materials are accurate and complete.
University Health Services IncClinical Documentation Coordinator FT ROC University Health Services IncClinical Documentation Coordinator FT ROCEDINBURG, TXNotice: At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient's true severity of illness, intensity of care, and risk of mortality.
MD AndersonClinical Studies Coordinator - Neuro Oncology MD AndersonClinical Studies Coordinator - Neuro Oncologyhouston, TXn \nUnderstand and adhere to the policies and procedures related to conduct of clinical trials as delineated in the department training manual and presented at weekly training meetings.\n \nCoordination of regulatory correspondence on clinical research studies: \n \nCommunicate verbally and in writing, as needed or as requested by the principal investigator of the study, with internal reviewers or external agencies (pharmaceutical companies and /or government sponsors). \n Opportunities for professional growth through Career Development Center and Mentoring programs.\n \nEDUCATION\n\n Required: Bachelor's Degree\n Preferred: Master's Degree Public Health or related scientific field.\n \nWORK EXPERIENCE\n\n Required: 3 years Research study or direct patient care experience obtained from nursing, data gathering or other related experience; With preferred degree, 1 year required experience.
MD AndersonAssistant Professor, Clinical Faculty Appointment (CFA), Anatomical Pathology MD AndersonAssistant Professor, Clinical Faculty Appointment (CFA), Anatomical Pathologyhouston, TXThe mission of The University of Texas MD Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public. To assume diagnostic patient care responsibilities by (a) serving as a surgical pathologist in subspecialty rotations(s), and (b) to develop and implement basic or clinical and translational research in the subspecialty field of surgical pathology appropriate for faculty rank.
MD AndersonClinical Studies Coordinator, Investigational Cancer Therapeutics MD AndersonClinical Studies Coordinator, Investigational Cancer TherapeuticsHouston, TXAct as a lead in data collection by retrieving protocol information via computer and visual chart review and by communicating directly with outlying healthcare providers to schedule and procure testing and treatment records. The performance for all expected outcomes is measured by observation by supervisor, reports from physicians and co-workers, the accuracy and timeliness of work produced, and the demonstrated ability to effectively work under stress.
InGenesisNewClinical Director - (13264) InGenesisClinical Director - (13264)El Paso, TXDepending on the detention facility physician requirement, proof of completion of three years of medical specialty training in Family Medicine, Internal Medicine, Emergency Medicine, or Pediatrics leading to board eligibility in that field, with board certification preferred, and at least 1 year of directly related, professional experience performing professional or scientific work in a field of medicine providing direct patient-care services. As the industry landscape shifts with new challenges in patient care, quality and compliance requirements, workforce retention, and operational efficiencies, we deliver strategic, data-driven solutions that include redefining workforce management and clinical service delivery.
Huntsville Memorial HospitalClinical Utilization Review RN Huntsville Memorial HospitalClinical Utilization Review RNHuntsville, TXUnder general supervision of the Director of Case Management, the Utilization Review Nurse provides a clinical review of cases using medical necessity criteria to determine the medical appropriateness of inpatient and outpatient services. Provides ongoing communication with the health plan, clinical providers (HMH Physicians/NPs) and care coordination departments regarding medical necessity for prospective, concurrent, and retrospective reviews.
Epitec, IncNewBehavioral Health Care Coordinator Epitec, IncBehavioral Health Care CoordinatorAustin, TXRemoteThis role combines clinical review and case management responsibilities, including reviewing medical records, assisting members via phone, coordinating care, and interpreting contract language related to behavioral health diagnoses. We are seeking a Behavioral Health Clinical Reviewer to ensure accurate and timely clinical review of behavioral health cases for medical necessity.
VytwoEpic Tapestry UM Analyst VytwoEpic Tapestry UM AnalystDallas, TXRemoteConfigure and optimize Tapestry UM workflows for prior authorizations (e.g., medical, behavioral health, pharmacy-to-medical crossovers) and referrals (in- and out-of-network), including routing rules, WQs, templates, smart text, decision trees, and notification logic. • Leverage Tapestry Care Link for external provider access—set up roles, security, workflows, documentation tools, and training materials to support referring providers, delegated entities, and partners.
Texas OncologyPatient Benefit Representative Sr Texas OncologyPatient Benefit Representative SrAustin, TexasTexas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas, our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. TheUS Oncology Network is supported by McKesson Corporation focused on empowering a vibrant and sustainable community patient care delivery system to advance the science, technology, and quality of care.
UWorld, LLCContinuing Medical Education (CME) Manager UWorld, LLCContinuing Medical Education (CME) ManagerIrving, TXThis role will lead the development of rigorous, exam-quality CME content designed to improve clinical reasoning, reinforce knowledge retention, and drive measurable learning outcomes. This individual will play a critical role in translating complex clinical concepts into high-yield, case-based learning experiences delivered through a best-in-class digital platform.
Texas OncologyPatient Benefits Representative Texas OncologyPatient Benefits RepresentativeAmarillo, TexasTexas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas, our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. TheUS Oncology Network is supported by McKesson Corporation focused on empowering a vibrant and sustainable community patient care delivery system to advance the science, technology, and quality of care.
Texas OncologyPatient Benefit Representative Texas OncologyPatient Benefit RepresentativeHouston, TexasTexas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas, our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. The Patient Benefit Representative role allows team members to make a meaningful impact by helping patients navigate insurance, financial responsibilities, and access to care during critical moments in their treatment journey.
Texas OncologyPatient Benefit Representative - Remote Texas OncologyPatient Benefit Representative - RemoteRichardson, TexasRemoteTexas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas, our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. TheUS Oncology Network is supported by McKesson Corporation focused on empowering a vibrant and sustainable community patient care delivery system to advance the science, technology, and quality of care.
Texas OncologyPatient Benefits Representative - MCD Texas OncologyPatient Benefits Representative - MCDDallas, TexasTexas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas, our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. TheUS Oncology Network is supported by McKesson Corporation focused on empowering a vibrant and sustainable community patient care delivery system to advance the science, technology, and quality of care.
Texas OncologyNewPatient Benefits Representative Sr Texas OncologyPatient Benefits Representative SrSan Antonio, TexasTexas Oncology is the largest community oncology provider in the country and has approximately 530 providers in 280+ sites across Texas, our founders pioneered community-based cancer care because they believed in making the best available cancer care accessible to all communities, allowing people to fight cancer at home with the critical support of family and friends nearby. TheUS Oncology Network is supported by McKesson Corporation focused on empowering a vibrant and sustainable community patient care delivery system to advance the science, technology, and quality of care.
Harris Health SystemPRN Utilization Management Review Nurse Harris Health SystemPRN Utilization Management Review NurseHouston, TXHarris Health is among an elite list of health systems in the U.S. achieving Magnet® nursing excellence designation for its hospitals the prestigious National Committee for Quality Assurance designation for its patient-centered clinics and health centers and its strong partnership with nationally recognized physician faculty residents and researchers from Baylor College of Medicine McGovern Medical School at The University of Texas Health Science Center at Houston UTHealth The University of Texas MD Anderson Cancer Center. As an essential healthcare system Harris Health champions better health for the entire community with a focus on low-income uninsured and underinsured patients through acute and primary care wellness disease management and population health services.
ConcentraNewEmergency Medicine Telecommute Medical Review Stream Physician ConcentraEmergency Medicine Telecommute Medical Review Stream PhysicianHouston, TexasCurrent, unrestricted clinical license(s) (or if the license is restricted, the organization has a process to ensure job functions do not violate the restrictions imposed by the State Board); -Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties is required for MD or DO reviewer. • Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer reviewed literature that support sound and objective decision making and rationales in reviews.
ConcentraNewHand Surgeon Medical Review Stream Physician ConcentraHand Surgeon Medical Review Stream PhysicianDallas, TexasCurrent, unrestricted clinical license(s) (or if the license is restricted, the organization has a process to ensure job functions do not violate the restrictions imposed by the State Board); -Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties is required for MD or DO reviewer. • Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer reviewed literature that support sound and objective decision making and rationales in reviews.
ConcentraNewSpine Telecommute Medical Review Stream Physician ConcentraSpine Telecommute Medical Review Stream PhysicianDallas, TexasCurrent, unrestricted clinical license(s) (or if the license is restricted, the organization has a process to ensure job functions do not violate the restrictions imposed by the State Board); -Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties is required for MD or DO reviewer. • Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer reviewed literature that support sound and objective decision making and rationales in reviews.
Oscar HealthUtilization Review Nurse Oscar HealthUtilization Review NurseDallas, TXRemote$35–$45.94 / hourActive, unrestricted RN licensure from the United States in [state], OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). Complete medical necessity reviews and level of care reviews for requested services using clinical judgment and Oscar Clinical Guidelines, Milliman Care Guidelines.
CHRISTUS HealthNewUtilization Review Nurse Health Plans - HP Utilization Management CHRISTUS HealthUtilization Review Nurse Health Plans - HP Utilization ManagementIrving, TXPerform provider outreach to address post-hospital discharge services, redirection to in-network providers for appropriate steerage, durable equipment usage, and utilization of other medical services and/or procedures and other necessary telephonic follow-up. This nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services.
University of Texas Medical Branch at GalvestonSpecialist, Poison Information I or II - TDH Poison Center University of Texas Medical Branch at GalvestonSpecialist, Poison Information I or II - TDH Poison CenterGalveston, TXESSENTIAL JOB FUNCTIONS Serves as an advanced resource to health professionals and the public related to potential poisonings by answering inquires (telephone calls and or other forms of communication) by providing consultation to include accurate assessment, information, direction, and assistance for the Texas Poison Center twenty-four hour statewide hot line and future forms of communication. ESSENTIAL JOB FUNCTIONS Serves as a resource to health professionals and the public related to potential poisonings by answering inquires (telephone calls and or other forms of communication) by providing consultation to include accurate assessment, information, direction, and assistance for the Poison Center twenty-four hour statewide hot line and future forms of communication.
Rio Vista Behavioral HealthDirector of Utilization Rio Vista Behavioral HealthDirector of UtilizationEl Paso, Texas