RN Utilization Management Specialist

University Health System- San Antonio; San Antonio (TX); On-site; USD 41,000 - 65,000; Full time

Job summary

Community First Health Plans in San Antonio, TX seeks a nurse to lead utilization management activities, including prior authorization, concurrent and retrospective reviews, and appeals. The role ensures medical necessity and appropriate care within regulatory guidelines.

The ideal candidate holds an RN license in Texas, with a BSN preferred, and at least two years in utilization management or related fields.

Qualifications

• RN license required in Texas.
• NCQA/URAC/CMS/Texas Medicaid compliance knowledge.
• Experience in Medicaid/Medicare or managed care preferred.

Responsibilities

• Perform utilization management activities including prior authorization, concurrent, retrospective, and appeal reviews.
• Evaluate medical necessity, level of care, and benefit coverage per criteria and policies.
• Collaborate with providers, Medical Directors, and interdisciplinary teams to ensure compliance and quality outcomes.

Skills

Utilization management

Prior authorization

Concurrent review

Appeals

Case management

Clinical nursing

Collaboration with providers

Education

Bachelor's degree in Nursing (BSN) preferred

Job description

Community First Health Plans in San Antonio, TX seeks a nurse to lead utilization management activities, including prior authorization, concurrent and retrospective reviews, and appeals. The role ensures medical necessity and appropriate care within regulatory guidelines.

The ideal candidate holds an RN license in Texas, with a BSN preferred, and at least two years in utilization management or related fields.