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About UHG

Careers at UnitedHealth Group

 

We have modest goals: Improve the lives of others. Change the landscape of health care forever. Leave the world a better place than we found it. Such aspirations tend to attract a certain type of person. Crazy talented. Compassionate. Driven. To these individuals, we offer the global reach, resources and can-do culture of a Fortune 5 company. We provide an environment where you’re empowered to be your best. We encourage you to take risks and in return, offer a world of rewards and benefits for performance. Exceeding your limits is an exceptional start to your life's best work.SM

 

Just like you, we are driven by a set of fundamental principles that are guiding our way forward. Our values of integrity, compassion, relationships, innovation, and performance serve as a foundation to transform health care. Are you in? Learn more about your future at UnitedHealth Group at careers.unitedhealthgroup.com

 

Job Category:

Nurse

Country:

US

Approximate Salary:

Not Specified

Position Type:

Full Time

Utilization Management RN Specialty Pharmacy--San Antonio, TX

UHG - San Antonio, Texas

Posted: 11/17/2018

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)  

 

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.

 

Primary 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 (e.g., patient level of care changes) regarding patient health and welfare (e.g., care and service coverage, safety)
  • Answer patient questions regarding care (e.g., medication, treatment) and benefit
  • Research and identify information needed to perform assessment, respond to questions, or make recommendations (e.g., navigate knowledge Library resources, and websites and databases such as MicroMedex and National Comprehensive Cancer Network)
  • Answer member and provider questions regarding care (e.g., medication, treatment) and benefits
  • Apply knowledge of pharmacological and clinical treatment protocol to determine appropriateness of care and instruct patients as needed
  • Demonstrate understanding necessary to assess, review and apply criteria (e.g., Milliman guidelines, CMS criteria, medical policy, WellMed Guidelines, plan specific 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.  Decision making is usually based on prior practice or policy, with some interpretation.  Applies individual reasoning to the solution of a problem devising or modifying processes and writing procedures
  • Performs all other related duties as assigned

Required Qualifications:

  • 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 5+ 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
  • Exhibits professionalism and is courteous with all patients, physicians and co-workers

Preferred Qualifications:

  • Experience with specialty pharmacy
  • Experience with Oncologic agents, Immunologic, or other specialty injectable
  • 2+ years practicing as a bedside nurse in an acute care setting

Physical and Mental Requirements:

  • Ability to lift up to 25 pounds
  • Ability to sit for extended periods of time
  • Ability to stand for extended periods of time
  • Ability to use fine motor skills to operate office equipment and/or machinery
  • Ability to receive and comprehend instructions verbally and/or in writing
  • Ability to use logical reasoning for simple and complex problem solving

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 240,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)


Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.


UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.

 

 

Job Keywords: RN, managed care, specialty pharmacy, San Antonio, Texas, TX, Wellmed, UHG, United Healthgroup

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