Clinical Evaluator - RN or LVN

Nexus Health Systems | Houston, Texas | Onsite

At Nexus Health Systems, we provide specialized care for patients with complex medical, behavioral health, and neurodevelopmental needs. Our interdisciplinary teams help patients access the care and support they need to achieve meaningful progress.

Nexus Health Systems is seeking an experienced Registered Nurse (RN) or Licensed Vocational Nurse (LVN) to join our team as a Clinical Evaluator.

In this role, you will review referrals, medical records, clinical histories, and assessment data to support decisions about patient admission and program placement. You will prepare comprehensive clinical evaluations and written summaries that support admission recommendations, medical necessity determinations, and insurance authorization requests.

The ideal candidate brings strong nursing experience, sound clinical judgment, and excellent documentation skills, with the ability to evaluate complex patient needs and communicate findings clearly. Responsibilities are performed within the applicable nursing scope of practice and in collaboration with clinical leadership.

Clinical Review & Evaluation

• Review referral documentation, medical records, clinical histories, and assessments to evaluate patient needs and potential program fit.

• Evaluate clinical information for patients with behavioral health conditions, autism spectrum disorder, intellectual and developmental disabilities, and medically complex needs.

• Review patient acuity, clinical risks, medical necessity, and level-of-care needs to support admission recommendations.

• Identify gaps in referral information and coordinate with referral sources and internal teams to obtain necessary documentation.

• Prepare accurate, comprehensive clinical evaluations and written summaries that clearly communicate findings, concerns, and recommendations.

• Apply nursing knowledge and critical thinking throughout the referral review process.

Medical Necessity & Authorization Support

• Prepare clinical documentation that supports medical necessity and meets commercial insurance, Medicaid, and other payer requirements.

• Apply knowledge of InterQual criteria, applicable CMS requirements, and payer-specific documentation standards.

• Identify potential documentation deficiencies or payer questions and address them proactively.

• Partner with admissions and authorization teams to support timely reviews and informed admission decisions.

• Maintain current knowledge of authorization criteria and relevant regulatory requirements.

Collaboration & Communication

• Collaborate with physicians, nursing teams, admissions staff, clinical leadership, and other interdisciplinary team members.

• Communicate clinical findings, potential risks, and recommendations clearly and professionally.

• Serve as a clinical resource for admissions and evaluation teams.

• Communicate respectfully and compassionately with families, clinicians, and referral sources, as needed.

Quality & Timeliness

• Manage multiple referrals and evaluations while maintaining accuracy, thoroughness, and attention to detail.

• Complete reviews within established turnaround expectations to support timely access to care.

• Maintain documentation that is complete, clinically supported, and consistent with organizational and payer standards.

• Identify opportunities to improve evaluation workflows, documentation quality, and admissions efficiency.

• Maintain current knowledge of the patient populations served, relevant assessment tools, and evidence-based clinical practices.

Education & Licensure

• Graduate of an accredited registered nursing or vocational nursing program.

• Current, unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license.

• Current Texas licensure or eligibility to obtain Texas licensure required.

Experience & Knowledge

• Minimum of three years of clinical nursing experience.

• Knowledge of InterQual criteria and applicable CMS regulations and requirements.

• Experience collaborating with interdisciplinary clinical teams.

• Experience in behavioral health, autism spectrum disorder, intellectual and developmental disabilities, pediatrics, or medically complex patient populations preferred.

• Previous experience in clinical review, utilization review, care management, admissions evaluations, or medical necessity review strongly preferred.

• Experience preparing clinical documentation for insurance authorization, Medicaid, or other funding approvals preferred.

Skills & Abilities

• Strong clinical judgment, critical thinking, and attention to detail.

• Excellent written communication and clinical documentation skills.

• Ability to interpret complex medical and behavioral health records.

• Understanding of clinical risk, medical necessity, and appropriate levels of care.

• Strong organizational skills and the ability to prioritize competing referrals.

• Effective interpersonal communication and collaboration skills.

• Proficiency with electronic medical record (EMR) and customer relationship management (CRM) systems.

This position is onsite in Houston, Texas. Some schedule flexibility may be required to support urgent or time-sensitive referrals.

Use your nursing expertise beyond the bedside while making a direct impact on patient access to specialized care. As a Clinical Evaluator, you will help ensure referrals receive thorough clinical review, support appropriate program placement, and strengthen the quality and efficiency of the admissions process.