Registered Nurse RN Medical Claims Review Nurse Healthcare WellMed – San Antonio, TX

UnitedHealth Group
Published
November 14, 2021
Location
San Antonio, TX
Category
Job Type

Description

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)  

Responsible for reviewing retrospective hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines. The Medical Claims Review Nurse determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Generally work is self-directed and not prescribed.  The Medical Claims Review Nurse works under the direct supervision of an RN or MD.
 
Primary Responsibilities:

  • Performs retrospective authorization reviews according to guidelines within a specific timeframe
  • Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria
  • Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
  • Answers Medical Claims directed telephone calls; managing them in a professional and competent manner
  • Refers case to a review physician when the treatment request does not meet medical necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times
  • Reviews, documents, and communicates all Medical Claims Review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member
  • May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
  • Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department
  • Identify and refer potential cases to Disease Management and Case Management
  • Performs all other related duties as assigned
  • Utilize appropriate resources to guide review decisions and document decisions clearly and concisely

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:

  • Current, unrestricted Texas RN license or compact state RN license 
  • 2+ years of experience in managed care, Utilization Review, Case Management or 5+ years nursing experience
  • Proficient in PC software computer skills that include Microsoft Word, Excel and Outlook

Preferred Qualifications:

  • Prior Authorization experience
  • Utilization Review/Management experience
  • ICD-9, ICD-10 , CPT coding knowledge/experience
  • InterQual or Milliman Knowledge/experience
  • Solid problem solving and analytical skills
  • Excellent communication skills both verbal and written skills
  • Ability to interact productively with individuals and with multidisciplinary teams
  • Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
  • Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies now require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles require full COVID-19 vaccination as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

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

Job Keywords: WellMed, Healthcare, Bilingual, RN, Registered Nurse, Medical Claims Review Nurse Prior Authorization, Managed care, Case Management / Manager, San Antonio, New Braunfels, Seguin, Gonzales, Helotes, Texas, TX

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