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Registered Nurse RN Prior Authorization Specialist
2 months ago
WellMed, part of the Optum family of businesses, is seeking a Registered Nurse RN Prior Authorization Specialist to join our team in San Antonio, TX.
As a clinician-led care organization, Optum 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 healthcare better for everyone.
This position is responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans for medical necessity and efficiency in accordance with CMS coverage guidelines.
The UM 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 Utilization Management Nurse works under the direct supervision of an RN or MD.
Key Responsibilities:- Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
- 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 healthcare services
- Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
- Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available
- Reviews, documents, and communicates all utilization review activities and outcomes, including 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
- Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies
- Documents rate negotiation accurately for proper claims adjudication
- Identify and refer potential cases to Disease Management and Case Management
- Performs all other related duties as assigned
This position requires 9AM-6PM CST/Monday-Friday and requires a rotating Saturday schedule with an adjustment day off during the week.
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
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.
