6 days old

Registered Nurse RN Utilization Management Nurse WellMed Texas

San Antonio, TX 78205
Apply Now
Apply on the Company Site
  • Job Code
    888449
  • Jobs Rated
    118th

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life's best work.(sm)  
 

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.

 

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

 The position requires a rotating Saturday shift.

 

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.

",

Jobs Rated Reports for Registered Nurse

Posted: 2020-10-13 Expires: 2020-11-13

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

Sponsored by:
ADP Logo

Before you go...

Our free job seeker tools include alerts for new jobs, saving your favorites, optimized job matching, and more! Just enter your email below.

Share this job:

Registered Nurse RN Utilization Management Nurse WellMed Texas

UnitedHealth Group
San Antonio, TX 78205

Join us to start saving your Favorite Jobs!

Sign In Create Account
Registered Nurse
118th2018 - Registered Nurse
Overall Rating: 118/220
Median Salary: $70,000

Work Environment
Poor
166/220
Stress
High
173/220
Growth
Good
53/220
Powered ByCareerCast