What are the responsibilities and job description for the Utilization Review III (RN) position at Medica?
Medica's Utilization Review Nurses are responsible for reviewing and documenting prior authorization requests and member case history in compliance with policies and procedures for approval of member coverage.
Medica's Utilization Review Nurses are also responsible for the analysis of trends through feedback, which may be identified through the review of cases, and for addressing these issues by recommending revision of medical policies and utilization management and/or clinical appeals policies.
Utilization review activities require interfacing with members, providers, clinics, medical directors, intake staff, case managers and other departments internally within Medica. This role requires attention to detail and use of clinical judgment to determine outcomes.
Qualifications
- Associate's or Bachelor's degree in Nursing
- 5 years clinical experience
- Previous utilization management experience preferred; clinical/hospital experience will also be considered
Certifications/Licensure
- Active, unrestricted RN license required
Skills and Abilities
- Demonstrated clinical assessment skills with the ability to think critically and make evidence-based decisions
- Self-motivated, autonomous worker with the ability to work independently but also collaboratively within a team environment
- Detail-oriented with strong organization skills
- Technology-savvy; ability to work within multiple computer applications
This position is a Remote role. The employee must be located in any state in which Medica is an employer and will work remotely 100% of the time.
The full salary range for this position is $67,100 - $115,100. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.
The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.
Medica's commitment to diversity, equity and inclusion (DEI) includes unifying our workforce through learning and development, recruitment and retention. We consistently communicate the importance of DEI, celebrate achievements, and seek out community partnerships and diverse suppliers that are representative of everyone in our community. We are developing sustainable programs and investing time, talent and resources to ensure that we are living our values. We are an Equal Opportunity/Affirmative Action employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
Equal Opportunity Employer including Veterans and Disabled Individuals
Salary : $67,100 - $115,100
