Nurse Prior Authorization Specialist

2 weeks ago

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

We are seeking a skilled Registered Nurse RN Prior Authorization Nurse to join our team in San Antonio, TX. As a 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 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 calls made and received in regard to case communication and demographic/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:
  • Authorization experience
  • Telephonic and/or telecommute experience
  • Utilization Review/Management experience
  • ICD-10, CPT coding knowledge/experience
  • InterQual or Milliman knowledge/experience
  • Proven excellent communication skills, both verbal and written
  • Proven solid problem-solving and analytical skills
  • Proven ability to interact productively with individuals and with multidisciplinary teams with minimal guidance

This is a full-time position, Monday-Friday, 9am-6pm CST, with a rotating Saturday schedule and an adjustment day off during the week. If you have a compact license, you will have the flexibility to work remotely as you take on some tough challenges.

We are 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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