RN Utilization Management Reviewer - Prior Authorization

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 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