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 proposed hospitalization, home care, and inpatient / outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines. The UM 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 Utilization Management Nurse works under the direct supervision of an RN or MD.
- Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
- 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 Utilization Management directed telephone calls; managing them in a professional and competent manner
- Refers case to a review physician when the treatment request does not meet 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 utilization 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
- Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies
- Documents rate negotiation accurately for proper claims adjudication
- Identify and refer potential cases to Disease Management and Case Management
- Performs all other related duties as assigned
The position requires a rotating Saturday shift.
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.
- Current, unrestricted Texas RN license or compact license
- 2+ years of experience in managed care OR 5+ years nursing experience
- Strong problem solving and analytical skills
- Proficient in PC Software computer skills
- Excellent communication skills both verbal and written skills
- Ability to interact productively with individuals and with multidisciplinary teams with minimal guidance
- Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
- Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive VoiceResponse (i.e., entering your symptoms via phone system) or a similar UnitedHealth Group approved symptom screener prior to entering the work site each day, in order to keep our work sites safe. Employees must comply with any state and local masking orders. In addition, when in a UnitedHealth Group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
- You will be asked to perform this role in an office setting or other company location, however, may be required to work from home temporarily due to space limitations
- Previous Prior Authorization experience
- Telephonic and/or telecommute experience
- Utilization Review / Management experience
- ICD-10, CPT coding knowledge / experience
- InterQual or Milliman Knowledge / experience
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, UHG, Bilingual, RN, Registered Nurse, Utilization Review / Management, Prior Authorization, Managed care, Case Management / Manager, San Antonio, Dallas, Houston, Corpus Christi, Forth Worth, Texas, TX