24 days old

Registered Nurse RN Utilization Management Nurse Pharmacy WellMed San Antonio TX

San Antonio, TX 78205
  • Job Code
    873659
  • Jobs Rated
    118th
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) 
  
WellMed provides concierge - level medical care and service for seniors, delivered by physicians and clinic staff that understand and care about the patient's health. WellMed's proactive approach focuses on prevention and the complete coordination of care for patients. WellMed is now part of the Optum division under the greater UnitedHealth Group umbrella.
 
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
This is an office based position located at our office off of Northwest Parkway in San Antonio, TX. The position requires a rotating Saturday shift.

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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Jobs Rated Reports for Registered Nurse

Posted: 2020-04-30 Expires: 2020-05-30

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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Registered Nurse RN Utilization Management Nurse Pharmacy WellMed San Antonio TX

UnitedHealth Group
San Antonio, TX 78205

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Registered Nurse
118th2018 - Registered Nurse
Overall Rating: 118/220
Median Salary: $70,000

Work Environment
Poor
166/220
Stress
High
173/220
Growth
Good
53/220
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