Registered Nurse RN Medical Claims Review Nurse Healthcare Texas

WellMed, part of the Optum family of businesses, is seeking a Registered Nurse RN Quality Auditor WellMed Healthcare to join our team in San Antonio, Texas. Optum is a clinician-led care organization that is changing the way clinicians work and live.

As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.

At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.

WellMed provides concierge – level medical care and service for seniors, delivered by physicians and clinic stat that understands 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.

Position in this function is 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 direction of the Director.

If you have compact licenses, you will have the flexibility to work remotely* as you take on some tough challenges.

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 RN license, applicable for practice in the applicable state

• 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

• Proven solid problem solving and analytical skills

• Proven excellent communication skills both verbal and written skills

• Demonstrated ability to interact productively with individuals and with multidisciplinary teams

• Demonstrated ability to possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills

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

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, Washington, or Washington, D.C. Residents Only: The salary range for this role is $58,300 to $114,300 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.

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.