Use your clinical expertise to shape fair, compliant medical necessity decisions from home. This role is ideal for experienced RNs who understand utilization management and appeals and want to move into a Monday through Friday, non-bedside position that still directly impacts member care.
About BroadPath
BroadPath partners with health plans and healthcare organizations to provide specialized remote teams across utilization management, appeals, claims, and member services. Their entire model is built around virtual work, with proven systems, training, and leadership to support nurses doing complex, policy-driven clinical work from home.
Schedule
- Full-time, work-from-home RN role
- Training: 2 weeks, Monday–Friday, 8:00 a.m.–5:00 p.m. CST
- Production: Monday–Friday, 8:00 a.m.–5:00 p.m. CST (flexible within that window)
- Occasional flexibility needed for pharmacy-related denials outside standard hours
- Weekly pay, with expectations for consistent attendance and productivity
What You’ll Do
- Partner with medical directors, physician reviewers, and clinical review staff to evaluate medical necessity appeals for compliance with HHSC and other regulatory standards
- Review requests against clinical guidelines, benefit allowances, and regulatory requirements, then implement appropriate actions and document decisions
- Coordinate continuity of care needs and advocate for members and families, including out-of-network authorization approvals when appropriate
- Prepare and generate appeal determination letters and maintain complete, compliant documentation in electronic and event tracking systems
- Communicate appeal status, rationale, due process, and regulatory requirements to members, legal authorized representatives, providers, and internal teams
- Coordinate Fair Hearing and External Medical Review processes and utilize Independent Review Organizations when needed
- Develop training materials and examples to help nurses and therapists understand criteria application, benefit use, and appeal processes
- Conduct quarterly assessments of appeal activity, prepare reports for internal leadership and the State of Texas, and support state reporting to avoid financial penalties
- Assist with audit preparation for NCQA and help build corrective action plans based on trended findings
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 policies, and medical necessity review, especially in pediatrics and obstetrics
- Excellent verbal and written communication skills with comfort speaking to physicians, members, families, and internal stakeholders
- Solid computer skills and ability to work in electronic tracking and documentation systems
- High level of independence, accountability, and attention to detail, with a strong team player mindset
Benefits
- Base pay up to 50 dollars per hour, with weekly pay
- Fully remote position with a stable Monday through Friday schedule
- Opportunity to move out of direct bedside care while still using your RN experience to advocate for appropriate, evidence-based care
- Work in a diverse, inclusive environment that values advanced clinical judgment and regulatory excellence
- Experience in a specialized UM and appeals role that is highly transferable across health plans and managed care organizations
If you are a Texas or compact RN ready to step deeper into utilization management and become the clinical voice inside the appeals process, this is a strong next move for your career.
Happy Hunting,
~Two Chicks…