POSITION SUMMARY AND RESPONSIBILITIES
Performs utilization management activities including prior authorization review, concurrent review, retrospective review, and appeal review activities utilizing approved medical necessity criteria, organizational policies, contractual requirements, and regulatory guidelines. 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, appropriate utilization of healthcare resources, and regulatory compliance. Reviews are completed in accordance with NCQA, URAC, CMS, Texas Medicaid, Medicare, and organizational requirements.
EDUCATION/EXPERIENCE
Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN) preferred. Minimum two (2) years of clinical nursing, utilization management, managed care, prior authorization, concurrent review, appeals, or case management experience required.
Working knowledge of:
• NCQA Utilization Management Standards
• URAC Utilization Management Standards
• CMS Managed Care requirements
• Texas Medicaid Managed Care regulations
• Medicare requirements, Medical necessity review criteria (InterQual®, MCG®, or organization-approved criteria)
• ICD-10-CM, CPT, and HCPCS coding principles
• Utilization management operations, including prior authorization, concurrent review, retrospective review, appeals, and denial management
• Regulatory compliance, documentation standards, and turnaround time requirements.
Experience reviewing Medicaid, Medicare, Marketplace, Commercial, CHIP, Dual Eligible Special Needs Plans (D-SNP), or other government-sponsored healthcare programs preferred. Experience in a managed care organization, health plan, delegated entity, or other regulated healthcare environment preferred.
LICENSURE
Current unrestricted Registered Nurse (RN) license issued by the Texas Board of Nursing is required. A Magnet recognized national certification is highly desirable. Certified Case Manager (CCM), Accredited Case Manager (ACM), or Utilization Management-related certification preferred.
We are looking for a talented Manager - Service Engineering to join our team specializing in Deployment & Field Operations for our First Mode. facility in Seattle, WA. Cummins acquired First Mode in 2025, a startup focused on developing battery-hybrid solutions for large...
...Job Description Job Description We are seeking a skilled Mechanic with expertise in hydraulic pump systems to perform maintenance and repairs independently. The ideal candidate will have a strong background in vehicle diagnostics, parts replacement, and safety inspections...
Medical Courier We're looking for a reliable and professional Medical Courier to transport time-sensitive medical materials including lab specimens, pharmaceuticals, medical equipment, and patient records between healthcare facilities, labs, and clinics.
...Temporary front desk/ admin Patient centered care, always trying to prioritize patient care... ...the phone calls/ appointment requests in a timely and courteous way Scheduling... ...punctuality are a plus Salary Range part-time $17 - $20 per hour - Competitive salary...
...facilities, and 19 manufacturing plants across 34 states and the District of Columbia. Our well-known banners include Albertsons, Safeway, Vons, Jewel-Osco, ACME, Shaw's, Tom Thumb, United Supermarkets, United Express, Randalls, Albertson's Market, Pavilions, Star Markets...