Nurse Case Manager - CFHP

Overview

Becoming a Nurse at University Health is a great way to step up and be there for the people of South Texas. They look up to us, and as a Nurse at UH, we’ll look to you to help carry out this mission in an environment that has been designated, and redesignated, as a Magnet Health Organization by the American Nurse Credentialing Center (ANCC) for more than a decade. From your first day, you’ll be hands on with our patients while gaining valuable experience, earning excellent benefits and making a real impact on people’s lives.

• Full Time

• Level:

• Travel: Minimal (if any)

• Salary: $63K-$96K

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Success Profile

What does it take to build a successful Nurse Case Manager - CFHP? career at University Health? Take a look the top qualities we’re after and see if you have the right mix.

• Collaborative

• Compassionate

• Empathetic

• Problem-solver

• Detail-oriented

• Strong Communicator

At University Health, we are strongly committed to quality, compassion and innovation in everything we do here and in our community.

This is a great place to be exposed to many different types of patients, procedures and disease processes.

• Lourdes Tuliao,

Acute Care Nurse

Learn more about what it means to be a nurse at University Health

Benefits

We believe in taking care of those who care for our community and provide each of our health care professionals with the benefits they need to thrive in all aspects of their lives.

Rewards

Learn about our rewards.

Healthcare

Medical: Excellent coverage for individuals and families with very low premiums and co-pays, and ZERO co-pays for medications filled at University Health. Dental, vision, pet insurance, flexible and health spending accounts.

Paid Time Off (PTO)

Generous accrual rates that start on day one.

Retirement

We offer both a 457(b) and 403(b) deferred compensation programs.

Education Reimbursement

Including college tuition reimbursement up to $600 per semester, continuing education up to $400 and certification reimbursement.

Life and Disability

Basic life paid by University Health, with optional plans for life and disability insurance.

Health and Wellness

Employee discounts, including gym memberships, employee health clinic, healing arts program, community events.

Responsibilities

Job Type | Day Shift Category | Nursing Job Schedule | Full Time Department | Population Health Management - CFHP

Position summary/responsibilities

Provides strategic leadership for Utilization Management programs and initiatives. Responsible for accreditation readiness, regulatory compliance oversight, performance improvement planning, delegated oversight, operational governance, and implementation of organizational UM strategies. Serves as a liaison between operational leadership, Medical Directors, executive leadership, regulatory agencies, and accreditation organizations.

Provides leadership, oversight, direction, and performance management for Utilization Management staff, including clinical reviewers, denial and appeals staff, and administrative personnel. Oversees utilization review operations, prior authorization activities, concurrent review, retrospective review, appeals support, and regulatory compliance activities. Ensures consistent application of medical necessity criteria, regulatory requirements, accreditation standards, and organizational policies.

Leads quality improvement initiatives, audit readiness activities, inter-rater reliability processes, staff development, and operational performance monitoring. 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.

Education/experience

Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN). A Master's degree is preferred.

Minimum five (5) years of Utilization Management experience and two (2) years of management or leadership experience are required.

Demonstrated knowledge of

• NCQA Utilization Management Standards

• URAC Utilization Management Standards

• CMS Managed Care requirements

• Texas Medicaid Managed Care regulations

• Medical necessity review criteria, including InterQual®, MCG®, and/or organization-approved clinical review criteria

• Utilization Management operations, including prior authorization, concurrent review, retrospective review, appeals, and denial management

• Regulatory compliance, accreditation readiness, quality improvement, and performance monitoring

Experience in a managed care organization, health plan, delegated entity, Medicare, Medicaid, or other regulated healthcare environment is preferred.

Licensure/ certifications

Current unrestricted Registered Nurse (RN) license issued by the Texas Board of Nursing is required . A Magnet recognized national certification is highly desirable. Certified Case Manager (CCM), Accredited Case Manager (ACM), Utilization Management Certification, or other related certification is required. If certification is not held at the time of hire, certification may be required within two (2) years of hire or transfer into the position, consistent with organizational requirements.

12238 Silicon Drive, San Antonio, TX, United States