You’ll need
Licensure
✓Current unrestricted Registered Nurse (RN) license issued by the Texas Board of Nursing is required.
Certifications
A Magnet recognized national certification is highly desirable. preferred
Certified Case Manager (CCM), Accredited Case Manager (ACM), or Utilization Management-related certification preferred.
Education
✓Graduate of an accredited school of professional nursing required.
Bachelor's degree in Nursing (BSN) preferred.
Qualifications
✓Minimum two (2) years of clinical nursing, utilization management, managed care, prior authorization, concurrent review, appeals, or case management experience required.
✓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.
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