Clinical Utilization Review Nurse

7 days ago


Boerne, Texas, United States UnitedHealth Group Full time
Job Summary

We are seeking a skilled Registered Nurse to join our team as a Utilization Management Nurse. In this role, you will be responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines.

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
  • Review, document, and communicate all utilization review activities and outcomes, including demographic and service group information
  • May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
  • Identify and refer potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to the Compliance Department
  • Conduct rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies
  • Document rate negotiation accurately for proper claims adjudication
  • Identify and refer potential cases to Disease Management and Case Management
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 include authorization experience, telephonic and/or telecommute experience, utilization review/management experience, ICD-10, CPT coding knowledge/experience, InterQual or Milliman knowledge/experience, and proven excellent communication skills
About UnitedHealth Group

UnitedHealth Group is a leading health care company that provides a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution. We are committed to diversity and inclusion, and we strive to create a work environment that is guided by these values.



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