Utilization Review RN III
About The Position
Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. The Utilization Review RN will review and document member case history in compliance with policies and procedures for approval of member coverage. The role requires attention to detail and use of clinical judgment to determine clinical benefits. RN Required. Perform other duties assigned.
Requirements
- Associate's or Bachelor's degree or equivalent experience in related field
- 5 years of work experience beyond degree
- RN license
- Active, unrestricted RN license required
- Eligibility to work in the US
- Legally authorized to work in the United States at the time of application.
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.
- Analysis of trends through feedback, which may be identified through the review of cases, and for addressing these issues by recommending revision of medical policies and utilization management policies.
- Interfacing with members, providers, clinics, medical directors, intake staff, case managers and other departments internally within Medica.
Benefits
- competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
