Nurse Care Manager

3 weeks ago


Floresville, Texas, United States Optum Full time
About Us

We believe all patients are entitled to the highest level of medical care at Optum. As part of our team, you'll be working towards making a difference in people's lives.

Job Summary

This is an exciting opportunity for a skilled Nurse Care Manager to join our team. As a key member, you will review proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency according to CMS coverage guidelines.

Main Responsibilities
  • Conduct thorough utilization reviews, including pre-certification, concurrent, and retrospective reviews as per established guidelines.
  • Determine medical necessity by applying relevant medical criteria and utilizing evidence-based guidelines/criteria.
  • Exercise sound judgment and critical thinking skills in evaluating requests and determining coverage for medically necessary healthcare services.
  • Handle directed telephone calls professionally and efficiently.
  • Refer cases to a reviewing physician when treatment requests don't meet necessity or guidelines are unavailable.
  • Document and communicate all utilization review activities and outcomes effectively.
  • Provide guidance and coaching to other utilization review nurses.
  • Identify and refer potential quality issues to the Clinical Quality Management Department and suspected fraud and abuse cases to the Compliance Department.
Required Qualifications
  • Current, unrestricted Texas RN license or compact license.
  • At least 2 years of experience in managed care or 5+ years of nursing experience.
  • Proficient in PC software computer skills.
Estimated Salary Range

$63,000-$90,000 per year, depending on experience and qualifications.


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