Clinical Reviewer Utilization Management

Jobtome; Boerne (TX); On-site; USD 80,000 - 110,000; Full time

Job summary

Jobtome is seeking an experienced Utilization Management RN in Texas to perform prior authorization, concurrent and retrospective reviews, and appeals, ensuring medical necessity and appropriate level of care. You will collaborate with providers and medical leadership to uphold quality outcomes and regulatory compliance.

Applicants should have at least two years in clinical nursing and UM-related roles, with Texas RN licensure and preferred certifications such as CCM/ACM.

Qualifications

• Graduate of an accredited school of professional nursing. RN license required in Texas.
• Minimum two (2) years of clinical nursing, utilization management, managed care, prior authorization, concurrent review, appeals, or case management experience required.
• Magnet recognition certification desirable; CCM/ACM/UM certifications preferred.

Responsibilities

• Performs utilization management activities including prior authorization, concurrent review, retrospective review, and appeal review.
• Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage within delegated authority.
• Collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes and regulatory compliance.
• Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.

Skills

NCQA Utilization Management Standards

URAC Utilization Management Standards

CMS Managed Care requirements

Texas Medicaid Managed Care

Medicare requirements

ICD-10-CM, CPT, HCPCS coding

Regulatory compliance

Documentation standards

Turnaround time management

Education

RN license (Texas)

Job description

POSITION SUMMARY AND RESPONSIBILITIES

Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review activities utilizing approved medical necessity criteria, organizational policies, contractual requirements, and regulatory guidelines. Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage within delegated authority. Collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate utilization of healthcare resources, and regulatory compliance. Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.

EDUCATION/EXPERIENCE

Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN) preferred. Minimum two (2) years of clinical nursing, utilization management, managed care, prior authorization, concurrent review, appeals, or case management experience required.

Working knowledge of:

• NCQA Utilization Management Standards
• URAC Utilization Management Standards
• CMS Managed Care requirements
• Texas Medicaid Managed Care regulations
• Medicare requirements, Medical necessity review criteria (InterQual®, MCG®, or organization-approved criteria)
• ICD-10-CM, CPT, and HCPCS coding principles
• Utilization management operations, including prior authorization, concurrent review, retrospective review, appeals, and denial management
• Regulatory compliance, documentation standards, and turnaround time requirements.

Experience reviewing Medicaid, Medicare, Marketplace, Commercial, CHIP, Dual Eligible Special Needs Plans (D-SNP), or other government-sponsored healthcare programs preferred. Experience in a managed care organization, health plan, delegated entity, or other regulated healthcare environment preferred.

LICENSURE

Current unrestricted Registered Nurse (RN) license issued by the Texas Board of Nursing is required. A Magnet recognized national certification is highly desirable. Certified Case Manager (CCM), Accredited Case Manager (ACM), or Utilization Management-related certification preferred.