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Utilization Management Nurse RN, WellMed, San Antonio, TX - Full-time / Part-time
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | San Antonio, TX San Antonio, Texas |
About this job
WellMed provides concierge-level medical care and service for seniors, delivered by physicians and clinic staff that understand and care about the patient's health. WellMed's proactive approach focuses on prevention and the complete coordination of care for patients. WellMed is now part of the Optum division under the greater UnitedHealth Group umbrella.
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
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
Nurses: tired of being a road warrior, working nights, or on call?
Join us in our air conditioned, modern offices!
Day shift Tuesday through Saturday - flexibility with Saturday hours
Join us in our air conditioned, modern offices!
Day shift Tuesday through Saturday - flexibility with Saturday hours
In this position, you will work in an office setting reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines. You will use your nursing knowledge to determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. You will work regular business hours Tuesday – Friday and flexible hours on Saturdays based on business needs. We offer the benefits of working for a Fortune 17 company – team work, career opportunities, great benefits, paid time off, and more!
- 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 turnaround 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.
- Identifies and refers 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.
- Identifies and refers potential cases to Disease Management and Case Management.
Requirements
Requirements:
- Current RN license, applicable for practice in the applicable state.
- Two years' experience in managed care OR Five years' experience as an RN.
- 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.
- Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills.
Preferred Education, Experience & Skills
- Previous Prior Authorization experience
- Utilization Review/Management experience
- ICD-9, CPT coding knowledge/experience
- InterQual or Milliman Knowledge/experience
WellMed is a healthcare delivery system serving more than 90,000 patients, primarily Medicare eligible seniors, in Texas and Florida through primary care clinics, multi-specialty clinics, and contracted medical management services. Headquartered in San Antonio, Texas, WellMed is an industry leader in medical risk management, highly effective disease management and chronic care programs, healthcare delivery services and more.
Our focus and mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. We are innovators in preventative healthcare, striving to change the face of healthcare delivery for seniors. Our providers and support staff are selected for their dedication to the senior population and focus on preventative, proactive patient care.
WellMed is now part of the OptumHealth division under the greater UnitedHealth Group umbrella.
Diversity creates a healthier atmosphere: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status, or disability status.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment. In addition, employees in certain positions are subject to random drug testing
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