The Utilization Management Nurse will determine the medical appropriateness of inpatient and outpatient services by evaluating medical guidelines, benefit determination and compliance with state mandated regulations. Essential functions include performing concurrent, retroactive and pre-service authorization reviews for inpatient and outpatient services, following and maintaining compliance with CMS requirements, and collaborating with staff, physicians, care/service coordinators, and medical directors to coordinate and provide the level of care necessary to meet member's health need.
Payor Utilization Management: 3 years recommended experience
Proficiency with Microsoft Office applications, specifically Word, Excel, and Outlook
Proficiency using Milliman Care Guidelines (MCG) and/or InterQual criteria
Current unencumbered LVN or RN license in Texas or compact license
2+ years Utilization management experience with a health insurance company (managed care/payer experience required)
About the employer
TEXAS INDEPENDENCE HEALTH PLAN INC
Hiring organization
Workplace not named in the posting.
Texas Independence Health Plan Inc is a health insurance/managed care organization based in Austin, Texas. Based on the available job description, the organization employs nurses in Utilization Management roles, where they evaluate the medical appropriateness of inpatient and outpatient services.…
What reviewers appreciate
+Nurses work in a collaborative environment with physicians, care coordinators, and medical directors
+Role involves diverse review types including concurrent, retroactive, and pre-service authorizations
+Focus on regulatory compliance provides structured framework for nursing practice
What reviewers flag
−Role is administrative rather than direct patient care, which may not appeal to all nurses
−Requires navigating complex medical guidelines and regulatory requirements
−Work involves benefit determination which can involve denied services and potential conflict
Austin blends Texas charm with live-music energy, outdoor living along Lady Bird Lake, and a booming tech-driven economy. Nurses relocating here will find a sun-sooked city where food trucks, hiking trails, and a friendly, fast-growing community define the lifestyle.
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