If you work in Texas as a case manager, care coordinator, utilization review nurse, service coordinator or prior-authorization reviewer, and you are paid a flat salary with no overtime, the exemption your employer is relying on is probably the administrative exemption — and it frequently does not hold. The question is not your title or your license. It is whether your actual daily work is the exercise of discretion and independent judgment on matters of significance, or whether it is applying the employer's clinical criteria and guidelines to decide whether a request meets them. No Texas statute requires a private employer to pay overtime, so this is a federal claim under the FLSA, and the remedy is the unpaid overtime plus an equal amount again in liquidated damages.
To hold you exempt as an administrative employee the employer must prove three things: that you are paid on a salary basis of at least $684 per week, or about $35,568 a year; that your primary duty is office or non-manual work directly related to management or general business operations; and that your primary duty includes the exercise of discretion and independent judgment with respect to matters of significance. The salary threshold is the easy part, and clearing it proves nothing on its own.
The third element is where these cases are decided. The regulations say that discretion and independent judgment has to be more than using skill to apply "well-established techniques, procedures or specific standards described in manuals or other sources." Case management and utilization review work is usually built around exactly that: InterQual or MCG criteria, a plan's medical policy, an approval matrix, a script, an escalation path to a medical director for anything the criteria do not clear. A reviewer who can approve what the criteria approve and must escalate everything else is not making the kind of independent judgment the exemption requires.
Jackson v. Superior HealthPlan, Inc. & Centene Company of Texas, L.P., Northern District of Texas. The court conditionally certified a collective of salaried Service Coordinators in November 2016. The motion was contested: the employer filed controverting declarations from other employees and argued for a more stringent standard. The court held that it is "improper at the initial notice stage to extend the analysis and 'perform a detailed review of individualized facts from employees hand-picked [by Defendants],'" and certified anyway. The order records what the job was — workers who averred their primary duties consisted of "making in-home visits to obtain participants' answers to standardized medical questionnaires, inputting data from those questionnaires, . . . and collecting medical authorizations," in a position the employer had designated "Clinical and Nursing" and classified as exempt regardless of actual responsibilities.
Outside Texas, this is the firm's deepest body of work, and one order in particular says what these cases are about.
In Pruess v. Presbyterian Health Plan, Inc. & Fluent Health, LLC, District of New Mexico, the court certified a Rule 23(b)(3) class of care coordinators under the New Mexico Minimum Wage Act in a 47-page opinion, denied the defendants' motion to decertify the FLSA collective, and divided that collective into a Care Coordinator subclass and a Utilization Management Nurse subclass — a ruling that treats UM nursing as its own job family rather than folding it into case management.
Conditional certification has also been granted for utilization review and care management employees against health plans and benefit administrators in Pennsylvania, Virginia and Ohio. In Bellan v. Capital BlueCross, Middle District of Pennsylvania, the employer's arguments were that the positions qualified for an exemption; the court held that "credibility determinations and merits-based arguments are more properly considered at the stage of final certification" and granted the motion. In Edwards v. Optima Health Plan, Eastern District of Virginia, the employer attacked the workers' declarations as boilerplate and inadmissible; the court answered on a fifteen-page memorandum opinion that "one would expect Plaintiffs subject to a common FLSA violation to have similar, and perhaps identical, experiences," and certified a collective of Care Management Employees.
Jack Siegel has filed more than 100 federal overtime lawsuits in 25 federal districts across 20 states and obtained 50+ class and collective certifications in 19 federal judicial districts across 14 states, as lead counsel on the firm's cases. The firm has recovered more than $100 million for workers, and it has never represented an employer in a wage case.
Prior results do not guarantee or predict a similar outcome in any future matter. These are results in other people's cases. Each case is decided on its own facts, its own record and its own procedural posture. Conditional certification and class certification are procedural rulings about whether a case may proceed as a group action; they are not findings of liability and they are not an award of money. This website contains attorney advertising.
Texas is in the Fifth Circuit, which since 2021 has not used the two-step conditional-certification process familiar from other circuits. Under Swales v. KLLM Transport Services, L.L.C., the district court identifies the facts and legal considerations material to whether the workers are similarly situated, authorizes preliminary discovery on those points, and then decides the scope of the collective once, rather than issuing lenient first-stage notice and taking the question up again on a decertification motion. Swales is the law of the circuit, which covers Texas, Louisiana and Mississippi.
For case management and utilization review that means building the record early around the things that are written down: the job description, the criteria set, the approval authority matrix, the escalation rules, the productivity targets. Those documents tend to be uniform across a team. Jackson was certified in 2016, under the two-step approach then in force, before Swales changed the framework.
Because a salary is a method of payment, not an exemption. The employer has to prove both the salary and that your primary duty involves the exercise of discretion and independent judgment on matters of significance. If your day is spent applying a plan's clinical criteria and escalating anything that falls outside them, that element is often missing, and you are owed time and a half for hours over 40.
It usually points the other way. The exemption regulations state that discretion and independent judgment must be more than the use of skill in applying well-established techniques, procedures or specific standards described in manuals or other sources. Working from a criteria set is the opposite of the independent judgment the exemption requires.
Not by itself, and the analysis is more specific than most employers admit. The regulations say that registered nurses registered by the appropriate state examining board generally meet the duties requirements for the learned professional exemption, while licensed practical nurses and other similar health care employees generally do not qualify. But an employer defending a utilization review or case management role usually relies on the administrative exemption rather than the professional one, because the work is reviewing and authorizing care rather than practicing nursing — and that puts the discretion-and-independent-judgment element squarely in issue. A court has already divided a certified class into a Care Coordinator subclass and a Utilization Management Nurse subclass, which is a recognition that the UM nurse role is its own question.
Not for your federal rights. The FLSA applies where you perform the work, so working remotely from Texas for an out-of-state plan does not change what you are owed. Because no Texas statute requires a private employer to pay overtime, a Texas-based worker has the federal claim alone, while a colleague doing the same job in New Mexico, Illinois or New York may also have a state wage claim with its own limitations period and damages.
It can be some of the best evidence in the case. A required number of reviews or touches per day, measured and enforced, tends to show work that is standardized and paced rather than discretionary — and it also tends to show why the work spilled past 40 hours in the first place.
The unpaid overtime premium for each week you worked over 40 hours, plus an equal additional amount as liquidated damages, plus your attorney's fees and costs from the employer if you prevail. The period reaches two years back from the date of filing, or three years if the violation was willful.
Attorney responsible: Jack L. Siegel, Dallas, Texas.
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Attorney advertising. Jack L. Siegel of Siegel Law Group PLLC, Dallas, Texas, is responsible for this content.
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