Clinical Reviewer Utilization Management

University Health System; San Antonio (TX); On-site; USD 42,000 - 65,000; Full time

Job summary

Community First Health Plans in Texas is seeking a full-time Utilization Management Nurse to perform prior authorization, concurrent, retrospective, and appeal reviews. You will assess medical necessity and coverage, ensuring appropriate utilization of resources within regulatory guidelines.

The role requires an RN with 2+ years in utilization management, managed care, or related fields. BSN preferred; familiarity with NCQA, URAC, CMS, and Texas Medicaid standards is essential.

Qualifications

• Graduate of an accredited school of professional nursing is required.
• BSN preferred.
• Minimum two 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 activities.
• Evaluates 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

Nursing

Utilization management

Prior authorization

Concurrent review

Case management

Regulatory compliance

Documentation

Education

RN licensure

BSN preferred

Tools

InterQual

MCG

Job description

Community First Health Plans

Population Health Management - CFHP

Full Time

Day Shift

Salary Range: $30.50 - $47.00

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.