RN Utilization Management

A large managed care organization is seeking a Utilization Management RN to perform reviews of specialty drugs appropriateness as applicable to Medicare Part B benefit. Note: Employer requires you must be fully vaccinated for COVID-19 Work Location: 5800 Northwest Pkwy, Ste 125 , San Antonio, TX 78249 Pay: $30.00 Contract Dates: Asap to 2/28/2022 Hours: Mon-Fri, 9-6 and rotating Saturdays (40 hours a week) 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). 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.

Created: 2021-11-29