Registered Nurse RN Prior Authorization Nurse WellMed Compact Lics

Opportunities at WellMed, part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind Caring. Connecting. Growing together.  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.If you are located in a Compact license state, you will have the flexibility to work remotely as you take on some tough challenges.Primary 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 health care 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. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times

Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, 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

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.Required Qualifications:

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

Excellent communication skills both verbal and written skills

Solid problem solving and analytical skills

Ability to interact productively with individuals and with multidisciplinary teams with minimal guidance

All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy.California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Hawaii, Nevada, New Jersey, New York, Rhode Island, or Washington residents is $58,300 to $114,300 annually. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.Diversity creates a healthier atmosphere: 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.UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.