Clinical Reviewer Utilization Management

Jobtome; Universal City (TX); On-site; USD 70,000 - 90,000; Full time

Job summary

Jobtome is seeking an experienced Registered Nurse for utilization management in Texas. You will perform prior authorization, concurrent and retrospective reviews, and appeals within approved criteria to determine medical necessity and coverage.

You will collaborate with providers, Medical Directors, and cross-functional teams to support regulatory compliance and high-quality care, following NCQA, URAC, CMS, and Texas Medicaid standards, with an emphasis on timely, accurate documentation and

Qualifications

• RN license in Texas is required.
• BSN preferred.
• Minimum two years in clinical nursing, utilization management, or related area.

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.
• Reviews are aligned with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.

Skills

Utilization management

Prior authorization

Concurrent review

Appeals

Regulatory compliance

Medical necessity review

Education

BSN (Bachelor of Science in Nursing)

Accredited nursing program graduate

Tools

InterQual/MCG criteria

ICD-10-CM, CPT, HCPCS coding

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.