Clinical Reviewer Utilization Management

Jobtome; Hondo (NM); On-site; USD 85,000 - 105,000; Full time

Job summary

Jobtome seeks a Registered Nurse to perform utilization management, including prior authorization, concurrent and retrospective reviews, and appeals under approved criteria.

You will collaborate with Medical Directors, Population Health Management, and providers to ensure quality care and regulatory compliance across TX Medicaid, CMS, and related standards.

RN license is required (TX license preferred); BSN is preferred with at least 2 years in UM, managed care, or case management.

Qualifications

• Graduate of an accredited school of professional nursing.
• 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.

Responsibilities

• Performs utilization management activities including prior authorization review, 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, appropriate utilization of healthcare resources, and regulatory compliance.
• Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.

Skills

Utilization management

Prior authorization

Clinical nursing

CMS regulatory knowledge

Education

RN license (Texas)

BSN preferred

Tools

InterQual criteria

MCG criteria

Organization-approved 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.