Austin, TX
Job Title: Service Delivery – Clinical Data Services Representative
Employment Type: Remote, Full-Time
Description
We are seeking a Clinical Data Services Representative to join our Health & Public Service (H&PS) team at Level 10. This role is designed for a Registered Nurse (RN) who will conduct pre-service, concurrent, and retrospective reviews to support quality member outcomes and ensure medically appropriate, cost-effective care. The position does not involve direct patient care and requires availability for shifts between 7:00 AM and 7:00 PM, with a standard schedule of 10:00 AM to 7:00 PM. Overtime may be required and must be approved.
Responsibilities
Conduct pre-service, concurrent, and retrospective reviews of outpatient and out-of-network services
Assess medical necessity and appropriateness of treatment settings within professional scope
Collaborate with healthcare providers to promote quality outcomes and optimize member benefits
Promote effective use of healthcare resources while ensuring compliance with Medicaid standards
Apply relevant rules from the Texas Administrative Code (TAC)
Review and interpret medical necessity requirements
Maintain accurate documentation and follow internal review procedures
Participate in team meetings and contribute to process improvement initiatives
Knowledge, Skills & Abilities
Strong understanding of Texas Administrative Code and Medicaid guidelines
Ability to assess medical necessity and treatment appropriateness
Effective collaboration and communication with healthcare providers
Proficiency in Microsoft Word and Excel preferred
Strong organizational and analytical skills
Ability to work independently and manage time effectively
Experience in clinical review or utilization management roles preferred
Requirements
Registered Nurse (RN) license in good standing
Availability to work 8-hour shifts between 7:00 AM and 7:00 PM, with a standard shift of 10:00 AM to 7:00 PM
No visa restrictions
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