Utilization Management Nurse - Prior Authorization & Appeals

Jobtome; Schertz (TX); On-site; USD 85,000 - 110,000; Full time

Job summary

Jobtome seeks a Registered Nurse with utilization management experience in Texas to review prior authorizations and care levels. The role evaluates medical necessity and coverage, ensuring compliance with NCQA, URAC, CMS, and state regulations.

The ideal candidate has 2+ years in nursing, knowledge of ICD-10-CM/CPT/HCPCS coding, and expertise in managed care settings. Nursing licensure in Texas is required.

Qualifications

• Graduate of an accredited school of professional nursing required.
• Bachelor's degree in Nursing (BSN) preferred.

Responsibilities

• Performs utilization management activities including prior authorization, concurrent, retrospective, and appeal reviews.
• Evaluates clinical information to determine medical necessity, appropriateness of care, level of care, and benefit coverage.
• 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

Utilization management standards

Regulatory compliance

Documentation standards

Medicare/Medicaid knowledge

Education

BSN (Bachelor of Science in Nursing)

RN license issued by Texas Board of Nursing

Job description

Jobtome seeks a Registered Nurse with utilization management experience in Texas to review prior authorizations and care levels. The role evaluates medical necessity and coverage, ensuring compliance with NCQA, URAC, CMS, and state regulations.

The ideal candidate has 2+ years in nursing, knowledge of ICD-10-CM/CPT/HCPCS coding, and expertise in managed care settings. Nursing licensure in Texas is required.