Registered Nurse RN Prior Authorization Nurse WellMed Compact Lics

About the position The Registered Nurse (RN) Prior Authorization Nurse at WellMed, part of the Optum family of businesses, plays a crucial role in ensuring that patients receive the highest level of medical care. This position is responsible for reviewing proposed hospitalization, home care, and inpatient/outpatient treatment plans to determine medical necessity and efficiency in accordance with CMS coverage guidelines. The Utilization Management (UM) Nurse evaluates the appropriateness of inpatient and outpatient services by applying medical guidelines and benefit determinations. The work is generally self-directed, allowing for flexibility and autonomy in decision-making, while still operating under the direct supervision of an RN or MD. In this role, the RN will perform utilization review activities, which include pre-certification, concurrent, and retrospective reviews according to established guidelines. The nurse will determine the medical necessity of each request by applying appropriate medical criteria to first-level reviews and utilizing approved evidence-based guidelines. Critical thinking and decision-making skills are essential as the nurse assesses coverage for medically necessary healthcare services. The position also involves managing Utilization Management directed telephone calls in a professional manner and referring cases to a review physician when treatment requests do not meet necessity per guidelines. Documentation is a key aspect of this role, as the RN will review, document, and communicate all utilization review activities and outcomes. This includes maintaining accurate records of all calls made and received regarding case communication, as well as sending appropriate system-generated letters to providers and members. The RN may also provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired nurses. Additionally, the nurse will identify and refer potential quality issues to the Clinical Quality Management Department and suspected fraud and abuse cases to the Compliance Department. The position requires a commitment to a schedule of 9 AM to 6 PM CST, Monday through Friday, with a rotating Saturday schedule and an adjustment day off during the week. The RN will be rewarded and recognized for their performance in an environment that challenges them and provides clear direction for success, along with opportunities for development in other roles. 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. , • Reviews, documents, and communicates all utilization review activities and outcomes including all calls made and received in regard to 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. , • Performs all other related duties as assigned. Requirements • Current, unrestricted Texas RN license or compact license , • 2+ years of experience in managed care OR 5+ years of nursing experience , • Proficient in PC Software computer skills Nice-to-haves • Authorization experience , • Telephonic and/or telecommute experience , • Utilization Review / Management experience , • ICD-10, CPT coding knowledge / experience , • InterQual or Milliman Knowledge / experience , • Proven excellent communication skills both verbal and written skills , • Proven solid problem solving and analytical skills , • Proven ability to interact productively with individuals and with multidisciplinary teams with minimal guidance Benefits • Opportunities for professional development , • Flexible work options for those with a Compact license , • Recognition for performance in a challenging environment Apply Job!