Utilization Management RN III

Medica•,

14h•$70,200 - $120,400•Remote

About The Position

Medica is a nonprofit health plan serving over a million members across multiple states. They focus on delivering personalized healthcare experiences and collaborating with providers. The company culture emphasizes accountability, data-driven decisions, continuous learning, and collaboration. The Utilization Review RN will review and document member case history to approve coverage, utilizing clinical judgment. An LPN or RN is required for this role, along with performing other assigned duties.

Requirements

Bachelor's degree or equivalent experience in a related field
5 years of work experience beyond degree
LPN or RN license
Active, unrestricted RN license required
Eligibility to work in the US; Medica does not offer work visa sponsorship.
Primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI

Nice To Haves

Experience with appeals strongly preferred
Utilization Management experience
Knowledge surrounding regulatory requirements (i.e. CMS and NCQA) specific to UM processes
Self-motivated, autonomous worker with the ability to work independently but also collaboratively within a team environment
Detail-oriented with strong organization skills
Technology-savvy; ability to work within multiple computer applications
Demonstrated clinical assessment skills with the ability to think critically and make evidence-based decisions

Responsibilities

Reviewing and documenting prior authorization requests and member case history in compliance with policies and procedures for approval of member coverage.
Analyzing trends through feedback from case reviews and recommending revisions to medical policies, utilization management, and/or clinical appeals policies.
Interfacing with members, providers, clinics, medical directors, intake staff, case managers, and other internal departments within Medica for utilization review activities.