RN Utilization Management Specialist – Prior Authorization & Appeals

Jobtome; Converse (IN); On-site; USD 70,000 - 100,000; Full time

Job summary

Jobtome is seeking a nursing professional to lead utilization management duties across prior authorization, concurrent and retrospective reviews, and appeals. You will assess medical necessity and coverage while aligning with policy and regulatory standards.

The role requires a BSN (preferred) and at least two years of related experience; familiarity with NCQA/URAC/CMS and coding principles is essential. RN licensure is required with certifications encouraged.

Qualifications

• Graduate of an accredited school of professional nursing; BSN preferred.
• Minimum two years of clinical nursing and utilization management experience.
• Knowledge of NCQA, URAC, CMS, Medicaid/Medicare requirements.
• Familiarity with ICD-10-CM, CPT, and HCPCS coding principles.
• Experience with prior authorization, concurrent, retrospective review, and denials.
• Experience with Medicaid/Medicare/Marketplace/Commercial programs preferred.
• RN license required; Magnet certification desirable; CCM/ACM preferred.

Responsibilities

• Perform utilization management activities including prior authorization, concurrent review, retrospective review, and appeal reviews.
• Evaluate clinical information to determine medical necessity and benefit coverage.
• Collaborate with providers, Medical Directors, Population Health Management, and interdisciplinary teams.
• Ensure reviews comply with NCQA, URAC, CMS, Texas Medicaid, and Medicare requirements.

Skills

Utilization management

Prior authorization

Concurrent review

Retrospective review

Appeals

Case management

Education

Bachelor's degree in Nursing (BSN) preferred

Tools

InterQual®/MCG criteria

Job description

Jobtome is seeking a nursing professional to lead utilization management duties across prior authorization, concurrent and retrospective reviews, and appeals. You will assess medical necessity and coverage while aligning with policy and regulatory standards.

The role requires a BSN (preferred) and at least two years of related experience; familiarity with NCQA/URAC/CMS and coding principles is essential. RN licensure is required with certifications encouraged.