RN Prior Authorization Specialist

3 weeks ago


San Antonio, Texas, United States UnitedHealth Group Full time
Job Summary

We are seeking a skilled RN Prior Authorization Specialist to join our team at UnitedHealth Group. As a key member of our Utilization Management team, you will play a critical role in reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency.

Key Responsibilities
  • Perform utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
  • Determine medical necessity of each request by applying appropriate medical criteria to first-level reviews and utilizing approved evidence-based guidelines/criteria
  • Utilize decision-making and critical-thinking skills in the review and determination of coverage for medically necessary healthcare services
  • Answer Utilization Management directed telephone calls; manage them in a professional and competent manner
  • Refer cases to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available
Requirements
  • Current, unrestricted Texas RN license or compact license
  • 2+ years of experience in managed care or 5+ years of nursing experience
  • Proficient in PC software computer skills
Preferred Qualifications
  • Authorization experience
  • Telephonic and/or telecommute experience
  • Utilization Review/Management experience
  • ICD-10, CPT coding knowledge/experience
  • InterQual or Milliman knowledge/experience

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.



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