21 days old

Pharmacy Utilization Management LVN

San Antonio, TX 78205
  • Job Code
    896276

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 Utilization 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
  • Gathers additional information and research requests for cases requiring presentation to medical director and/or Clinical Pharmacist
  • Generates referral entries accurately identifying the covered services authorized including ICD-9/ICD-10 coding, service groups and appropriate medical terminology in text
  • 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
The schedule is 9-6 or 10-7 (rotating Saturday's / Holidays)


You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

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Posted: 2020-11-03 Expires: 2020-12-03

UnitedHealth Group is the most diversified health care company in the United States and a leader worldwide in helping people live healthier lives and helping to make the health system work better for everyone.

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Pharmacy Utilization Management LVN

UnitedHealth Group
San Antonio, TX 78205

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