RN Prior Authorization Nurse Healthcare Compact Lics

About the position WellMed, part of the Optum family of businesses, is seeking a RN Prior Authorization Nurse to join our team. Optum is a clinician-led care organization that 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 health care better for everyone. Join us and discover how rewarding medicine can be while 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. The Utilization Management Nurse works under the direct supervision of an RN or MD. This position requires 9AM - 6PM - CST / Monday - Friday and requires a rotating Saturday schedule with an adjustment day off during the week.

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
• 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
• 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

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

Nice-to-haves

• 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 skills
• Proven solid problem solving and analytical skills
• Proven ability to interact productively with individuals and with multidisciplinary teams with minimal guidance

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution

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