Pharmacy Utilization Management LVN

UnitedHealth Group
November 21, 2020
San Antonio, TX
Job Type


The Utilization Management Nurse for Medical Management Pharmacy is responsible for utilization review and the coordination of members Medicare Part B medication through UM Pharmacy staff, Medical Directors and various other departments. This position will perform Utilization Reviews of specialty drugs appropriateness as applicable to Medicare Part B benefit.

Primary Responsibilities:

  • Collaborates with the providers to recommend policies, procedures and standards which affect the care of the member
  • Provide summary clinical and ancillary information to Clinical Pharmacist and Medical Director for review and decision making for targeted Part B medications
  • Gathers additional information and research requests for cases requiring presentation to medical director and/or Clinical Pharmacist
  • Generates referral entries accurately identifying the covered services authorized including ICD-9/ICD-10 coding, service groups and appropriate medical terminology in text
  • Discuss patient care specifics with peers or providers involved in overall patient care and benefits
  • Advocate with physicians and others for appropriate decisions (e.g., patient level of care changes) regarding patient health and welfare (e.g., care and service coverage, safety)
  • Answer patient questions regarding care (e.g., medication, treatment) and benefit
  • Research and identify information needed to perform assessment, respond to questions, or make recommendations (e.g., navigate knowledge Library resources, and websites and databases such as MicroMedex and National Comprehensive Cancer Network)
  • Answer member and provider questions regarding care (e.g., medication, treatment) and benefits
  • Apply knowledge of pharmacological and clinical treatment protocol to determine appropriateness of care and instruct patients as needed
  • Demonstrate understanding necessary to assess, review and apply criteria (e.g., Milliman guidelines, CMS criteria, medical policy, WellMed Guidelines, plan specific criteria)
  • Demonstrate knowledge of process flow of UM including prior authorization, concurrent authorization and/or clinical appeal and grievance reviews
  • Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. Decision making is usually based on prior practice or policy, with some interpretation. Applies individual reasoning to the solution of a problem devising or modifying processes and writing procedures
  • Performs all other related duties as assigned
The schedule is 9-6 or 10-7 (rotating Saturday's / Holidays)

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • High School diploma or GED required
  • Current LVN license in state of Texas
  • Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
  • Previous experience in Physician Office as clinical LVN is required
  • Proficient in PC software computer skills
  • Must have sound knowledge of managed care, medical terminology, referral process, and ICD-9/ICD-10 coding
  • Independent problem identification and resolution of patient issues originated by unfavorable decisions regarding medical care in support of physician reviewer decision by education of benefits and criteria standards
  • The schedule is 9-6 or 10-7 (rotating Saturday's / Holidays)

Preferred Qualifications:

  • Experience with specialty pharmacy preferred. Experience with Oncologic agents, Immunologic, or other specialty injectable highly desirable.
  • 2 years of experience in managed care or referral management position
  • 4-7 years clinical experience in primary care physician office or hospital setting
  • Excellent verbal and written skills
  • Ability to interact productively with individuals and with multidisciplinary teams

Careers with WellMed. Our focus is simple.We're innovators in preventative health care, striving to change the face ofhealth care for seniors., WellMed is a network of doctors, specialists andother medical professionals that specialize in providing care for 550,000+ older adults with over 16,000 doctors'offices in Texas and Florida through primary and multi-specialty clinics, andcontracted medical management services. We've joined Optum, part of theUnitedHealth Group family of companies, and our mission is to help the sickbecome well and to help patients understand and control their health in alifelong effort at wellness. Our providers and staff are selected for theirdedication and focus on preventative, proactive care. For you, that means oneincredible team and a singular opportunity to do yourlife's best work.(sm)

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

Job Keywords: Quality LVN, Pharmacy, San Antonio, TX, Texas

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