Clinical Reviewer Utilization Management

University Health & Rehabilitation Center; San Antonio (TX); On-site; USD 43,000 - 65,000; Full time

Job summary

Community First Health Plans is seeking an experienced Registered Nurse for utilization management. The role focuses on prior authorization, concurrent and retrospective review, and appeals within regulatory and contractual guidelines.

You will evaluate medical necessity and benefit coverage while collaborating with providers and interdisciplinary teams to ensure high-quality, cost-effective care. The position requires a Texas RN license, a BSN preferred, and at least two years of clinical

Qualifications

• RN licensure in Texas required.
• BSN preferred.
• Minimum two years of clinical nursing, UM, managed care, prior authorization, concurrent review, appeals, or case management experience required.
• Knowledge of NCQA Utilization Management Standards, URAC, CMS
• Familiarity with ICD-10-CM, CPT, and HCPCS coding principles.

Responsibilities

• Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review.
• Evaluates medical information to determine medical necessity, level of care, and benefit coverage.
• 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

Utilization management

Clinical nursing

Prior authorization

Review coordination

Interdisciplinary collaboration

Education

RN license (Texas)

BSN preferred

CCM/ACM preferred

Tools

InterQual® criteria

MCG® criteria

ICD-10-CM coding

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.