RN Utilization Management/Pharmacy San Antonio Texas

UnitedHealth Group • San Antonio, TX

150d • $58,800 - $105,000 • Onsite

About The Position

WellMed, part of the Optum family of businesses, is seeking a Utilization Management Nurse to join our team in San Antonio, TX. 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. 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. The Utilization Management Nurse for Medical Management Pharmacy is responsible for utilization review and the coordination of members Medicare Part B medication through UM Pharmacy staff, Medical Directors and various other departments. This position will perform reviews of specialty drugs appropriateness as applicable to Medicare Part B benefit.

Requirements

• Registered Nurse with a current license to practice in the state of employment
• Current unrestricted RN Licensure to practice in the applicable states
• 2+ years of experience in managed care, Utilization Review, Case Management or five years nursing experience
• Relevant experience in UM process activities such as prior authorization or medical claims review
• Medical terminology, ICD-9/ICD-10 and CPT knowledge
• Proficiency with Microsoft Office applications

Nice To Haves

• 2+ years practicing as a bedside nurse in an acute care setting
• Experience with specialty pharmacy
• Experience with Oncologic agents, Immunologic, or other specialty injectable highly desirable
• Exhibits professionalism and is courteous with all patients, physicians and co-workers

Responsibilities

• Collaborates with the providers to recommend policies, procedures and standards which affect the care of the member
• Provide summary clinical and ancillary information to Clinical Pharmacist and Medical Director for review and decision making for targeted Part B medications
• Discuss patient care specifics with peers or providers involved in overall patient care and benefits
• Advocate with physicians and others for appropriate decisions regarding patient health and welfare
• Answer patient questions regarding care and benefit
• Research and identify information needed to perform assessment, respond to questions, or make recommendations
• Answer member and provider questions regarding care and benefits
• Demonstrate understanding necessary to assess, review and apply criteria
• Demonstrate knowledge of process flow of UM including prior authorization, concurrent authorization and/or clinical appeal and grievance reviews
• Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives
• Performs all other related duties as assigned

Benefits

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

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree