Clinical Reviewer Utilization Management

Jobtome; New Braunfels (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

Jobtome is seeking a Registered Nurse with 2+ years in utilization management to perform prior authorization, concurrent, retrospective, and appeal reviews. You will evaluate medical necessity and benefit coverage while ensuring regulatory compliance.

The role requires a Texas RN license and BSN preferred, with familiarity with CMS and state Medicaid regulations. Collaboration with providers and medical directors is essential.

Qualifications

• RN licensed in Texas with an unrestricted license.
• Minimum of 2 years in clinical nursing, utilization management, managed care, prior authorization, concurrent review, appeals, or case management.
• Strong knowledge of NCQA, URAC, CMS, Texas Medicaid, Medicare regulations.
• Familiarity with ICD-10-CM, CPT, HCPCS coding principles.

Responsibilities

• Perform utilization management activities including prior authorization, concurrent review, retrospective review, and appeal review.
• Evaluate clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage.
• Collaborate with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes and regulatory compliance.
• Complete reviews in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.

Skills

Utilization management

Clinical nursing

Prior authorization

Appeals

CMS regulations

Education

Bachelor's degree in Nursing (BSN)

RN license (TX)

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.