RN Utilization Management Specialist

Jobtome; New Braunfels (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

Jobtome is seeking a Registered Nurse with 2+ years in utilization management to perform prior authorization, concurrent, retrospective, and appeal reviews. You will evaluate medical necessity and benefit coverage while ensuring regulatory compliance.

The role requires a Texas RN license and BSN preferred, with familiarity with CMS and state Medicaid regulations. Collaboration with providers and medical directors is essential.

Qualifications

• RN licensed in Texas with an unrestricted license.
• Minimum of 2 years in clinical nursing, utilization management, managed care, prior authorization, concurrent review, appeals, or case management.
• Strong knowledge of NCQA, URAC, CMS, Texas Medicaid, Medicare regulations.
• Familiarity with ICD-10-CM, CPT, HCPCS coding principles.

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.
• Complete reviews in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.

Skills

Utilization management

Clinical nursing

Prior authorization

Appeals

CMS regulations

Education

Bachelor's degree in Nursing (BSN)

RN license (TX)

Tools

InterQual®, MCG® criteria

Job description

Jobtome is seeking a Registered Nurse with 2+ years in utilization management to perform prior authorization, concurrent, retrospective, and appeal reviews. You will evaluate medical necessity and benefit coverage while ensuring regulatory compliance.

The role requires a Texas RN license and BSN preferred, with familiarity with CMS and state Medicaid regulations. Collaboration with providers and medical directors is essential.