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UH
University Health
Clinical Reviewer Utilization Management
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Job Description
Clinical Reviewer Utilization Management University Health Pleasanton, TX
- On-Site Apply Nursing Medicare Medicaid Operations Management Managed Care Case Management Health Policies Turnaround Time Clinical Nursing Medical Necessity Population Health Denial Management Prior Authorization Delegated Authority Regulatory Compliance Registered Nurse (RN) Retrospective Reviews Software Documentation Utilization Management Hospital Information Systems Certified Case Manager (CCM) Accredited Case Manager (ACM) Healthcare Common Procedure Coding Systems At least 2 years STARs-friendly $30.
STARs-friendly:
Skilled Through Alternative Routes. 35 % STARs in role.Description:
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.