Utilization mgmt nurse rn/26/nur132 - united states, san antonio oeste
adecco medical and science is assisting our client to find a remote utilization mgmt. rn nurse in san antonia, tx.
primary responsibilities:
• performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
• determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria
• utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
• answers utilization management directed telephone calls, managing them in a professional and competent manner
• refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within cms or urac mandated turnaround times
• reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received regarding case communication and all demographic and service group information. sends appropriate system-generated letters to provider and member
• may provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
• identify and refer all potential quality issues to the clinical quality management department, and suspected fraud and abuse cases to compliance department
• conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies
• documents rate negotiation accurately for proper claims adjudication
• identify and refer potential cases to disease management and case management
the position requires a rotating saturday shift.
education/certification:
• high school diploma/ged
• current, unrestricted texas rn license or compact license
required qualifications:
• must be covid vaccinated
• 2+ years of experience in managed care or 5+ years nursing experience
• strong problem solving and analytical skills
• proficient in pc software computer skills
• excellent communication skills both verbal and written skills
• ability to interact productively with individuals and with multidisciplinary teams with minimal guidance
• possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
• employees are required to screen for symptoms using the protectwell mobile app, interactive voiceresponse (i.e., entering your symptoms via phone system) or a similar unitedhealth group approved symptom screener prior to entering the work site each day, to keep our work sites safe. employees must comply with any state and local masking orders. in addition, when in a unitedhealth group building, employees are expected to wear a mask in areas where physical distancing cannot be attained
preferred qualifications:
• previous prior authorization experience
• telephonic and/or telecommute experience
• utilization review / management experience
• icd-10, cpt coding knowledge / experience
• interqual or milliman knowledge / experience
why work for • weekly • 401(k) • skills • excellent medical, dental, and vision benefits
important: this job is being recruited for by adecco’s national recruitment center, not your local adecco branch office. to be considered for this position, you must use the “apply with adecco” button to submit your resume.
the adecco group is a global leader in hr services. our group connects over 700,000 associates with our business clients each day through our 6,600 offices in over 70 countries and territories around the world. we offer employment opportunities at any stage in your professional career. contact us today to discuss available contract and direct hire positions. adecco group provides one of the most comprehensive benefits packages in the industry to contract workers to include holiday, 401(k), insurance benefit plans
equal opportunity employer minorities/women/veterans/disabled
adecco will consider qualified applicants with arrest and conviction records for employment
equal opportunity employer/veterans/disabled
the company will consider qualified applicants with arrest and conviction records
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