RN Utilization Management Reviewer: PA & Appeals

Jobtome; San Antonio (TX); On-site; USD 72,000 - 110,000; Full time

Job summary

The RN Utilization Management position performs prior authorization review, concurrent review, retrospective review, and appeal review activities using medical necessity criteria, policies, and regulatory guidelines.

The role collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate use of healthcare resources, and compliance with NCQA, URAC, CMS, Texas Medicaid, and Medicare requirements.

Qualifications

• 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.
• Experience with Medicaid/Medicare/Marketplace/Commercial programs preferred.
• Current unrestricted RN license in Texas is required. Magnet certification desirable. CCM/ACM/UM certification preferred.

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 and regulatory compliance.
• Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.

Skills

NCQA UM Standards

URAC UM Standards

CMS Managed Care

Texas Medicaid regs

Medicare criteria (InterQual/MCG)

ICD-10-CM, CPT, HCPCS

UM operations (POA, concurrent, retro)

Compliance & documentation

Education

RN program graduate

BSN preferred

Job description

The RN Utilization Management position performs prior authorization review, concurrent review, retrospective review, and appeal review activities using medical necessity criteria, policies, and regulatory guidelines.

The role collaborates with providers, Medical Directors, Population Health Management, and interdisciplinary teams to promote quality outcomes, appropriate use of healthcare resources, and compliance with NCQA, URAC, CMS, Texas Medicaid, and Medicare requirements.