Clinical Reviewer

Clinical Reviewer Nexus Health Systems | Houston, TX | Onsite Position Summary Nexus Health Systems is seeking an experienced Clinical Reviewer to support the evaluation and admission of patients into our specialized behavioral health, neurodevelopmental, and medically complex programs. The Clinical Reviewer reviews medical records, clinical histories, assessments, and referral documentation to determine clinical appropriateness and program fit. This position develops thorough, high-quality clinical evaluations and summaries that support admission and authorization decisions while meeting the documentation requirements of commercial insurance, Medicaid, and other funding sources. We are specifically seeking an experienced Registered Nurse (RN) or Nurse Practitioner (NP) with strong clinical judgment, excellent documentation skills, and experience evaluating complex patient needs. Nurse Practitioners with clinical leadership experience are strongly encouraged to apply , as this position may offer opportunities for expanded leadership responsibilities within the clinical evaluation team. What You'll Do Clinical Review & Evaluation Review incoming referrals, medical records, clinical histories, assessments, and supporting documentation to determine clinical appropriateness and program fit. Evaluate patients with behavioral health conditions, autism spectrum disorder, intellectual and developmental disabilities, and medically complex needs. Assess patient acuity, clinical risk, medical necessity, and appropriateness for Nexus programs. Identify missing or insufficient clinical information and obtain additional documentation necessary to complete the evaluation. Develop clear, comprehensive clinical evaluations and summaries supporting admission and authorization decisions. Apply sound nursing judgment and critical thinking when evaluating complex referrals. Payer & Authorization Support Prepare clinical documentation that supports medical necessity and meets commercial insurance, Medicaid, and other payer requirements. Maintain knowledge of payer authorization criteria, documentation standards, regulatory requirements, and evolving funding policies. Ensure clinical evaluations are accurate, complete, timely, and defensible. Anticipate potential payer questions or documentation deficiencies and proactively address them during the review process. Support efficient authorization and admission processes through strong clinical documentation. Collaboration & Communication Collaborate with referral sources, physicians, nursing teams, admissions staff, clinical leadership, and other interdisciplinary team members. Communicate with referral sources to clarify clinical information and obtain missing documentation. Clearly communicate clinical findings, concerns, and recommendations to internal stakeholders. Interact professionally and compassionately with patients, families, clinicians, and referral partners. Serve as a clinical resource throughout the referral and evaluation process. Quality & Timeliness Manage multiple clinical evaluations and referrals simultaneously while maintaining accuracy and atten