RN Utilization Management Specialist - Prior Authorization

Jobtome; Boerne (TX); On-site; USD 80,000 - 110,000; Full time

Job summary

Jobtome is seeking an experienced Utilization Management RN in Texas to perform prior authorization, concurrent and retrospective reviews, and appeals, ensuring medical necessity and appropriate level of care. You will collaborate with providers and medical leadership to uphold quality outcomes and regulatory compliance.

Applicants should have at least two years in clinical nursing and UM-related roles, with Texas RN licensure and preferred certifications such as CCM/ACM.

Qualifications

• Graduate of an accredited school of professional nursing. RN license required in Texas.
• Minimum two (2) years of clinical nursing, utilization management, managed care, prior authorization, concurrent review, appeals, or case management experience required.
• Magnet recognition certification desirable; CCM/ACM/UM certifications preferred.

Responsibilities

• Performs utilization management activities including prior authorization, 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 Utilization Management Standards

URAC Utilization Management Standards

CMS Managed Care requirements

Texas Medicaid Managed Care

Medicare requirements

ICD-10-CM, CPT, HCPCS coding

Regulatory compliance

Documentation standards

Turnaround time management

Education

RN license (Texas)

Job description

Jobtome is seeking an experienced Utilization Management RN in Texas to perform prior authorization, concurrent and retrospective reviews, and appeals, ensuring medical necessity and appropriate level of care. You will collaborate with providers and medical leadership to uphold quality outcomes and regulatory compliance.

Applicants should have at least two years in clinical nursing and UM-related roles, with Texas RN licensure and preferred certifications such as CCM/ACM.