UM Nurse: Managed Care Review Specialist

Gonzaba Medical Group; Cassin (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

Gonzaba Medical Group is seeking a UM Nurse to focus on the UM Review Process within a busy managed care setting at the San Antonio clinic. The role requires 5+ years in Managed Care/Utilization Management, RN with an associate degree or LPN with clinic experience, and preferred BSN.

Strong knowledge of EMR systems, HIPAA, and bilingual English/Spanish are a plus. Responsibilities include summarizing records, composing denial letters per CMS standards, monitoring referrals in EZ Cap, and

Qualifications

• Active, unencumbered RN with an associate degree or state-licensed practical nurse with one year of clinic experience.
• BSN preferred and licenses must be current to remain employed.
• Minimum 5 years of experience in Managed Care and Utilization Management.

Responsibilities

• Provides clinical input to UM Review team and Referral Specialists.
• Summarizes medical records documentation for medical necessity review.
• Composes denial letters per CMS standards and UM delegation rules.
• Applies evidence-based criteria to reviews and documents in the review summary.
• Oversees daily authorizations and ensures timely, compliant referral documentation.
• Pulls and submits ODAG/Part C reports and other UM reports to health plans by deadlines.
• Supports audits and ensures UM criteria are available to providers on request.

Skills

Bilingual English/Spanish

HIPAA compliance

Communication skills

Education

RN with Associate degree

LPN with 1 year clinic experience

BSN preferred

Tools

EMR systems

Office software

Job description

Gonzaba Medical Group is seeking a UM Nurse to focus on the UM Review Process within a busy managed care setting at the San Antonio clinic. The role requires 5+ years in Managed Care/Utilization Management, RN with an associate degree or LPN with clinic experience, and preferred BSN.

Strong knowledge of EMR systems, HIPAA, and bilingual English/Spanish are a plus. Responsibilities include summarizing records, composing denial letters per CMS standards, monitoring referrals in EZ Cap, and