Utilization Review Nurse - RN (WHWC)

Monday thru Friday- 8am-5pm

Onsite location: Wesley Health & Wellness Center, 1406 Fitch Street, San Antonio, Texas

Position Summary

The Utilization Review Nurse (RN) supports care coordination by reviewing clinical documentation, evaluating medical necessity, and facilitating communication between providers and care teams to ensure appropriate, timely, and patient-centered care.

Scope and Impact

This role impacts patient outcomes across the care continuum by ensuring appropriate utilization of healthcare services, supporting referral processes, and promoting adherence to care coordination and patient-centered medical home principles.

Decision Making Authority

Exercises clinical judgment in reviewing patient records, determining appropriateness of care, and identifying next steps within established guidelines and protocols. Escalates complex cases as needed.

Interactions / Working Relationships • Internal

• Care Coordination team (RN/LVN/MA), Patient Referral Coordinators, primary care providers
• External: Specialty providers, physician offices, multidisciplinary care teams
• Frequent communication with clinics and external partners to coordinate patient care and referrals

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• Essential Duties and Responsibilities
• 30% Review patient records, referral notes, and treatment plans to determine medical necessity and appropriate level of care
• 15% Coordinate with specialty providers and internal teams to ensure continuity of care and timely processing of referrals
• 10% Enter, maintain, and document clinical information in electronic health record (EHR) and medical management systems
• 10% Process pre-authorizations and diagnostic orders in collaboration with Patient Referral Coordinators
• 10% Communicate patient status updates, appointment scheduling, and follow-up care with clinics and providers
• 10% Provide patient and family education regarding conditions, treatments, and care plans
• 5% Ensure compliance with HIPAA regulations and organizational policies
• 5% Promote patient-centered medical home principles and support care coordination initiatives