Clinical Reviewer Utilization Management

Jobtome; Converse (IN); On-site; USD 70,000 - 100,000; Full time

Job summary

Jobtome is seeking a nursing professional to lead utilization management duties across prior authorization, concurrent and retrospective reviews, and appeals. You will assess medical necessity and coverage while aligning with policy and regulatory standards.

The role requires a BSN (preferred) and at least two years of related experience; familiarity with NCQA/URAC/CMS and coding principles is essential. RN licensure is required with certifications encouraged.

Qualifications

• Graduate of an accredited school of professional nursing; BSN preferred.
• Minimum two years of clinical nursing and utilization management experience.
• Knowledge of NCQA, URAC, CMS, Medicaid/Medicare requirements.
• Familiarity with ICD-10-CM, CPT, and HCPCS coding principles.
• Experience with prior authorization, concurrent, retrospective review, and denials.
• Experience with Medicaid/Medicare/Marketplace/Commercial programs preferred.
• RN license required; Magnet certification desirable; CCM/ACM preferred.

Responsibilities

• Perform utilization management activities including prior authorization, concurrent review, retrospective review, and appeal reviews.
• Evaluate clinical information to determine medical necessity and benefit coverage.
• Collaborate with providers, Medical Directors, Population Health Management, and interdisciplinary teams.
• Ensure reviews comply with NCQA, URAC, CMS, Texas Medicaid, and Medicare requirements.

Skills

Utilization management

Prior authorization

Concurrent review

Retrospective review

Appeals

Case management

Education

Bachelor's degree in Nursing (BSN) preferred

Tools

InterQual®/MCG criteria

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.