RN Utilization Management Specialist: Prior Auth & Appeals

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

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