Utilization Management RN

Medica•,

1d•$70,200 - $120,400•Remote

About The Position

Medica is a nonprofit health plan serving more than one million members in Minnesota, Nebraska, Wisconsin, Missouri, and other areas. The Utilization Review RN reviews and documents prior authorization requests and member case histories in accordance with policies and procedures to determine approval of member coverage. The role requires attention to detail and clinical judgment in assessing clinical benefits. The RN analyzes trends identified through case reviews and recommends revisions to medical policies and utilization management and/or clinical appeals policies. The position interfaces with members, providers, clinics, medical directors, intake staff, case managers, and other internal departments. Other duties may be assigned. This is a remote position. Candidates must have a primary home address in a 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, or WI. Medica does not offer work visa sponsorship; candidates must be legally authorized to work in the United States when applying, and employment is contingent on verification of identity and work eligibility.

Requirements

Associate's or bachelor's degree, or equivalent experience in a related field.
At least 5 years of related work experience beyond degree.
Active, unrestricted RN license.
Legally authorized to work in the United States at the time of application; employment is contingent on verification of identity and eligibility to work in the United States.
Primary home address must be in a 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, or WI.

Nice To Haves

Utilization Management experience.
Knowledge of regulatory requirements specific to UM processes, such as CMS and NCQA.
Self-motivated, autonomous worker able to work independently and collaboratively within a team.
Detail-oriented with strong organizational skills.
Technology-savvy, with the ability to work within multiple computer applications.
Demonstrated clinical assessment skills and ability to think critically and make evidence-based decisions.

Responsibilities

Review and document prior authorization requests and member case histories in compliance with policies and procedures to determine approval of member coverage.
Analyze trends identified through case reviews and recommend revisions to medical policies and utilization management and/or clinical appeals policies.
Interface with members, providers, clinics, medical directors, intake staff, case managers, and other internal departments.
Perform other duties as assigned.