Use your RN experience to advocate for members and families while working from home. This role focuses on utilization management appeals, clinical reviews, and making sure members receive fair, timely, and compliant decisions on their care.
About BroadPath
BroadPath partners with leading health organizations to support clinical, operational, and member service functions across the country. They specialize in remote healthcare roles, compliance driven workflows, and technology enabled teams. You will join a company that values flexibility, performance, and diversity in a fully remote environment.
Schedule
- Full time, remote
- Training: Monday through Friday, 8:00 a.m. to 5:00 p.m. CST for 2 weeks
- Production: Monday through Friday, 8:00 a.m. to 5:00 p.m. CST (some flexibility based on business needs)
- Weekly pay
What You’ll Do
- Review medical necessity appeals to ensure compliance with HHSC and other regulatory requirements.
- Collaborate with physician reviewers, clinical staff, and network providers to determine appropriate decisions and guideline citations.
- Advocate for members and families, including supporting continuity of care and out of network authorization approvals when appropriate.
- Develop training materials and examples for nursing staff on criteria application, benefits, appeals, External Medical Review, and Fair Hearing processes.
- Monitor appeal timeliness, decision making, and processing against regulatory and accreditation standards.
- Communicate case status, rationale, and due process to members, legal authorized representatives, providers, and internal teams.
- Coordinate Fair Hearing and EMR requests, including work with Independent Review Organizations as needed.
- Maintain accurate documentation and recordkeeping in electronic systems and generate appeal determination letters.
- Educate clinical reviewers and physician reviewers on managed care and Medicaid policies and processes.
- Assist with appeal file preparation for NCQA reviews, audit activities, and corrective action planning.
- Analyze appeal trends and prepare internal and external reports, including state reporting to HHSC.
What You Need
- Active RN license for the state of Texas or a compact RN license.
- At least 3 years of nursing experience.
- At least 1 year of utilization management and appeals experience.
- Strong understanding of managed care, Medicaid, and clinical criteria application, especially in complex pediatrics and obstetrics.
- Excellent verbal and written communication skills, including clear documentation.
- Comfortable working independently in a remote environment with a strong team mindset.
- Solid computer skills and ability to work with electronic documentation, event tracking systems, and common office software.
Benefits
- Competitive hourly pay up to 50 dollars per hour.
- Weekly pay schedule.
- Fully remote role with a consistent Monday through Friday daytime schedule.
- Training provided for systems, processes, and regulatory requirements.
- Inclusive culture that values diversity and professional growth.
Hiring now for motivated RNs who want to move into or deepen their work in utilization management and appeals.
If you are ready to use your clinical voice to protect member rights and support fair, compliant decisions, this role is built for you.
Happy Hunting,
~Two Chicks…