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.
...those that are committed to these same values. We are currently seeking self-motivated, results oriented RETAIL SALES AND MERCHANDISING ASSOCIATE (SEASONAL ). It is Micro Centers core promise to take care of our associates and customers which has led to our success...
...Job Description Job Description Title: Data Engineer/Analyst Location: Warwick, RI Start Date: Immediately Duration: 6 months, possible extensions Position Summary The Data Analytics Analyst designs, develops, and supports enterprise data, reporting,...
As a Catering Event Lead at Aramark, youll oversee the setup, service, and breakdown of catered events across education, healthcare, business, and sports venues. Youll coordinate with culinary and service teams, direct event staff, and serve as on-site contact for clients...
...the strength of more than 100 years of experience and renowned engineering expertise to meet the needs of today's mission and stay ahead... ...of 8 years of prior relevant experience Professional electrical engineering design experience to include electronic design, troubleshooting...
...family-oriented, supportive, and drama-free. I'm a very engaged agent who believes in working alongside my team and helping them... .... Location Address: Metairie, LA 70003 At Kert Leblanc - State Farm Agent, were here to help people protect what matters most. We...