UNKNOWN

FEED

Within the case management role, within the scope of licensure will assess, develop, implement coordinate, monitor, and evaluate care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their specific health needs. Within the medical management role will collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical transplant issues.

Elevance Health Inc

Transplant Nurse II

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Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred or any combination of education and experience, which would provide an equivalent background, Multi-state licensure is required if this individual is providing services in multiple states. Primary duties may include, but are not limited to: Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions and extensions of stay, outpatient services, out of network services, and appropriateness of treatment setting and level of care.

Elevance Health

Nurse Care Manager I (Nclex)

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The Senior Bioinformatics (BI) Software Engineer holds a critical technical role, responsible for designing, developing, and maintaining scalable and efficient software solutions for Baylor Genetics' bioinformatic pipelines. Dashboard & Report Creation:Develop interactive dashboards and automated reports using BI tools (e.g., Azure Pipelines, Teams Power Automate, email, Nextflow) to provide actionable insights for stakeholders.

Baylor Miraca Genetics Laboratories LLC

Sr Bioinformatics Software Engineer

Guided by our HEART values of Humility, Excellence, Accountability, Respect, and Trust, we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals.

Texas Children's Hospital

Denial and Appeal Coordinator

Collaborates with Medical Directors, Care Management, Provider Relations, Compliance, Quality Management, and other departments to ensure appropriate utilization of healthcare resources, timely determinations, regulatory compliance, and member-centered care. Provides leadership, oversight, direction, and performance management for Utilization Management staff, including clinical reviewers, denial and appeals staff, and administrative personnel.

University Health

Nurse Case Manager - CFHP

Baylor Genetics

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Job Summary: Reporting to the Chief Medical Officer of Prominence Health Plan (PHP), the Medical Director will direct the development of goals and objectives and the activities related to their achievement for the Health Services Department of PHP which include Utilization Management, Care Management, Disease Management, Quality Improvement, Pharmacy Management, Risk Adjustment, and Community Provider Relations. This medical leader will be responsible for strategically developing and enhancing the existing Medical Management Service Department in the areas of medical policy and procedures, utilization management, peer-to-peer clinical review, pharmacy management, quality of care, quality of service, physician enhancement and development, case/disease management, and appropriate documentation and coding.

University Health Services Inc

Medical Director

Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare. What You Will Be Doing: Serve as the Physician match reviewer in Radiation Oncology and imaging cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.

HOUR

Evolent

Radiation Oncology Field Medical Director

IRecruitee

Ensures utilization management requests are processed timely and accurately in accordance with regulatory, contractual, accreditation, and organizational turnaround time requirements EDUCATION/EXPERIENCE A high school diploma or equivalent is required. POSITION SUMMARY RESPONSIBILITIES Serves as the primary point of contact for utilization management authorization requests received by telephone, fax, electronic submission, provider portal, or other designated intake channels.

Intake Representative - CFHP

OTHER

Texas 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. Uses Technical and Functional Experience: Possesses up to date knowledge of the profession and industry; is regarded a san expert in the technical/functional area; accesses and uses other expert resources when appropriate.

Texas Oncology

Patient Benefits Representative

[AW]-iCims

Patient Benefits Representative Sr. Float

Patient Benefits Representative Sr.

Certified Professional in Healthcare Risk Management (CPHRM) by the American Hospital Association (AHA) requiredRegistered Nurse (RN) State Licensure or Nurse Licensure Compact (NLC) by the Texas Board of Nursing (BON) required Minimum Education:Bachelor''s Degree in Nursing required, Master''s Degree in a healthcare-related field, and/or MBA preferred Minimum Experience:7 years of experience in a hospital/hospital system, clinic health care, patient safety, or clinical quality management required Experience in healthcare risk management, contracts management, or a healthcare-related regulatory or legal environment required Experience practicing as a Registered Nurse (RN) in a clinical setting 5 years of management experience leading people and projects preferred Physical Requirements:Exerts up to 20 pounds of force occasionally and/or up to 10 pounds frequently and/or a negligible amount constantly to move objects. UTHealth Houston is looking for a Director of Healthcare Risk Management (RN) who will be responsible for the planning, implementation, and effectiveness of a system of internal controls that provides reasonable assurance that healthcare risk management operations are effective and efficient, organizational assets are protected, and financial information is reliable and compliant with applicable laws, regulations, policies, and procedures.

University of Texas Health Science Center at Houston

Director Healthcare Risk Management in Legal Affairs (RN required)

Minimum of three (3) years of prospective utilization management experience making medical necessity determinations (prior authorization, pre-service review or precertification) at a health plan, utilization management organization, or specialty or radiology benefit manager. Monitors case inventory, queues and turnaround times throughout the day, and adjusts the nurse assignment tool based on staffing, proficiency, request type and volume so client service levels and regulatory turnaround times are met.

YEAR

WNS (Holdings) Ltd

Nurse Team Lead - Clin Rev

Design and expose tools to agents via function-calling and Model Context Protocol (MCP) servers, wrapping internal APIs, databases, and enterprise systems as safe, well-scoped agent capabilities. We are hiring an AI Engineer to design, build, and operate agentic AI systems - LLM-powered agents that reason over enterprise data, call tools, and execute multi-step workflows end to end.

Sunrise Systems was founded in 1990 with a clear vision to deliver world-class staffing service solutions in all labor categories, including IT consulting and solutions; all with the commitment to provide service that exceeds expectations and become the most trusted name in the industry. More than two and a half decades later, we pride ourselves on being at the forefront of the staffing industry. Combining our deep industry expertise, insights, and global resources, we have partnered with our clients to connect them with top professionals across several different industries.
We provide cost-effective Managed Staffing Solutions, Information Technology and Information Technology Consulting Services to several Fortune 500 companies and U.S. Government agencies. We provide our clients with flexible engagement models and customized products that are budget and time specific. Understanding the challenges that every business faces, we offer our services either on-site at the clients' site or from one of our globally distributed technology centers. Our onshore and offshore development capabilities ensure that we excel at meeting customer requirements every single time.
Our collective business experience spans over two and a half decades and ranges from:
<ul>
<li>Business, management, and technical fields</li>
<li>Information technology consulting and software solutions.</li>
<li>Providing strategic support for the development and long-term growth of new business ventures across several industries including but not limited to; accounting, banking, finance, and recruitment.</li>
<li>Motivating technology staff and establishing partnerships with Fortune 500 companies</li>
</ul>
Sunrise Systems has a vast range of competence in:
<ul>
<li>Design, development, and support of cloud-based solutions from simple to highly complexed</li>
<li>Database administration of multi-platform applications, complex databases, and web-based environments that include all aspects of installation, planning, maintenance, and monitoring.</li>
<li>Data processing and data migration</li>
<li>Application re-engineering and platform migration</li>
<li>Working with the Information Systems and end-user communities at all levels to resolve issues and establish consensus.</li>
</ul>

Sunrise Systems Inc

AI Engineer - Agentic Systems

This role ensures the agency's employee health practices related to nursing employees — including TB screening, immunization tracking, communicable disease monitoring, exposure management, and personnel health recordkeeping — meet or exceed the requirements of each state's home health/home care licensing authority, and serves as the organization's subject-matter expert on employee health regulatory compliance during new-state licensure applications, surveys, and accreditation reviews. Develop, revise, and implement organizational protocols for staff exposure to infection-control hazards in the home setting, including patient home pest infestations (bed bugs, lice, rodents), following established PPE/decontamination procedures and criteria for visit suspension pending remediation.

CSI Pharmacy

Regulatory and Compliance Nurse

FULL_TIME

Minimum of three (3) years of prospective utilization management experience making medical necessity determinations (prior authorization, pre-service review or precertification) at a health plan, utilization management organization, or specialty or radiology benefit manager . Monitors case inventory, queues and turnaround times throughout the day, and adjusts the nurse assignment tool based on staffing, proficiency, request type and volume so client service levels and regulatory turnaround times are met.

Clinical Reviewer Jobs in Texas

Transplant Nurse II Elevance Health Inc

Nurse Care Manager I (Nclex) Elevance Health

Nurse Care Manager I (Nclex) Elevance Health Inc

Sr Bioinformatics Software Engineer Baylor Miraca Genetics Laboratories LLC

Denial and Appeal Coordinator Texas Children's Hospital

Nurse Case Manager - CFHP University Health

Sr Bioinformatics Software Engineer Baylor Genetics

Medical Director University Health Services Inc

Radiation Oncology Field Medical Director Evolent

Intake Representative - CFHP University Health

Patient Benefits Representative Texas Oncology

Patient Benefits Representative Sr. Float Texas Oncology

Patient Benefits Representative Sr. Texas Oncology

Director Healthcare Risk Management in Legal Affairs (RN required) University of Texas Health Science Center at Houston

Nurse Team Lead - Clin Rev WNS (Holdings) Ltd

AI Engineer - Agentic Systems Sunrise Systems Inc

Regulatory and Compliance Nurse CSI Pharmacy

Nurse Team Lead - Clin Rev HealthHelp - A WNS Company

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