Director of Utilization Review (RN) – Midland/Odessa, Texas

The Utilization Review RN is responsible for ensuring that all behavioral health patients receive the appropriate level of care, and that all services rendered meet medical necessity, payer requirements, Texas Behavioral Health regulations, and DNV accreditation standards.

The UR RN performs utilization review activities, concurrent reviews, precertifications, and discharge-related authorization functions to support timely reimbursement and high-quality patient care.

We offer a competitive and comprehensive compensation package including:

• Health Insurance - variety of plans
• Dental Insurance
• Vision Insurance
• Life Insurance
• AD & D Insurance 
• Hospital Indemnity Insurance
• Critical Illness Insurance
• HSA
• FSA
• Employee Assistance (EAP)
• Disability Insurance
• Unlimited PTO
• 8 Holidays
• Relocation Assistance

Responsibilities Include:

1.Utilization Management & Medical Necessity

• Conduct admission, continued-stay, and discharge reviews for all patients based on:
  • InterQual®, MCG, or payer-specific medical necessity criteria.
  • CMS Conditions of Participation (where applicable).
  • DNV NIAHO® Behavioral Health standards.
• Validate appropriate level of care (inpatient, PHP, IOP, detox, residential).
• Identify and communicate variances to medical necessity, collaborating with providers to resolve clinical or authorization barriers.

2.Insurance & Authorization Management

• Initiate pre-certifications for admissions and transfers.
• Perform concurrent reviews with commercial, Medicaid, Medicare Advantage, and managed care organizations.
• Submit clinical documentation within required time frames to prevent denials.
• Manage peer-to-peer requests and escalate cases to physician advisors as needed.
• Track and document authorization numbers, approved days, and review dates in EMR and UR software.

3.Compliance & Accreditation (DNV / Texas-specific)

• Ensure UR processes comply with:
  • DNV NIAHO®/ISO 9001 requirements for utilization management.
  • Texas Administrative Code Title 25—Behavioral Health Facility regulations.
  • CMS, EMTALA (if applicable), and payer rules.
• Participate in audits, tracer activities, and performance improvement projects.
• Maintain accurate and complete documentation that meets DNV documentation standards.

4.Interdisciplinary Collaboration

• Work with physicians, nursing, case management, therapy, social work, and admissions to coordinate patient flow and progression of care.
• Attend daily treatment team meetings on assigned units.
• Communicate authorization status, updates, and denials to clinical teams.

5.Denial Prevention & Management

• Identify potential denial risks early and intervene proactively.
• Assist with preparation of denial appeals, supplying clinical summaries and supporting documentation.
• Work with billing and revenue cycle to ensure claims accuracy and timely submission.

6.Documentation & Data Management

• Enter all reviews, payer communications, and clinical updates into the EMR/UR tracking system.
•  Maintain UR logs, KPIs, and dashboards for:

o LOS monitoringo Denial rateso Approval trendso Payer mix and reimbursement

o Report trends to leadership for process improvement

Qualifications:

Required

• Current Texas RN license (unencumbered).
• Minimum 2 years psychiatric/behavioral health nursing experience.
• Experience with utilization review, case management, or managed care.
• Knowledge of InterQual®/MCG criteria.
• Strong understanding of behavioral health diagnoses, treatment modalities, and levels of care.
• Excellent communication and negotiation skills.

Preferred

• Prior UR/UM experience in a Texas behavioral health facility.
• Familiarity with DNV Accreditation (NIAHO®/ISO 9001).
• Experience with Medicaid/Medicare behavioral health authorization processes.
• Experience with EMRs such as Epic, Cerner, MediTech, or Sigmund.

CORE COMPETENCIES

• Clinical assessment and critical thinking
• Knowledge of utilization review criteria
• Strong professional communication
• Time management and organization
• Understanding of behavioral health regulations
• Accuracy and attention to detail
• Collaboration and conflict resolution
• Ethical decision-making

PHYSICAL & WORK REQUIREMENTS

• Office-based with regular unit rounds and team meetings.
• Ability to type, sit, or stand for extended periods.
• Occasional lifting of files or equipment (<20 lbs).
• Must maintain confidentiality and meet HIPAA, DNV, and Texas regulatory standards.

ADDITIONAL DUTIES

• Participate in staff training related to utilization management.
• Support hospital-wide performance improvement projects.
• Assist with payer education and communication initiatives.
• Other duties as assigned by the Director of UR or Clinical Leadership.

The Permian Basin Behavioral Health Center is a mental health facility located between Midland and Odessa. The Center will provide inpatient and outpatient mental health services to help individuals of all ages overcome their challenges. This exciting partnership between Midland County Hospital District and Ector County Hospital District marks the start of a new chapter in the future of behavioral health in the Permian Basin.  PBBHC is scheduled to open spring 2026.