Utilization Mgmt Nurse RN- $3000 Sign on Bonus- San Antonio, TX

*****$3000 Sign on BONUS*****
 
We are pleased to announce that we are hosting a Nurses Meet and Greet in Dallas, TX on September 8th at the DFW Airport Marriot from 4-8pm Central and want to formally invite you to join us! This informal event will give you the opportunity to speak with professionals from our organization about what it is like to be a part of the WellMed family, delivering concierge-level medical care and service for seniors. For registration and more information, please follow this link: uhg.hr/WellMedRNMandG2. We look forward to meeting you and learning more about your career motivations!
 
There's an energy and excitement here, a shared mission to improve the lives of others as well as our own. Can you feel it? Bring that energy to a role that helps us offer a higher level of care than you'll find anywhere else. Put your skills and talents to work in an effort that is seriously shaping the way health care services are delivered. As a Utilization Management Nurse you will be responsible for ensuring proper utilization of our health services. This means you will be tasked with assessing and interpreting member needs and identifying solutions that will help our members live healthier lives. This is an inspiring job at a truly inspired organization. Ready for a new path? Join us and start doing 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.
 
 
Clinic Hours:
M-F
8-5 
 
 

Essential Job Functions

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

Minimum Required Education, Experience & Skills

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
 
Physical & Mental Requirements:

Ability to lift up to 10 pounds
Ability to sit for extended periods of time
Ability to use fine motor skills to operate office equipment and/or machinery
Ability to receive and comprehend instructions verbally and/or in writing
Ability to use logical reasoning for simple and complex problem solving
 
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 90,000+ 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: 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. Certain positions are subject to random drug testing.
 
 
Job Keywords: Utilization Review Management, Case Management, Pre Auth, RN , Registered Nurse, San Antonio, TX, Texas