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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/Hybrid position located at our office near HWY/ Rims Shopping CTR., San Antonio, TX. The position requires rotating Saturday and holiday shifts (premium pay offered)

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.

Required Qualifications:

• Registered Nurse with a current license to practice in the state of employment

• Current unrestricted RN Licensure to practice in the applicable states

• 2+ years of experience in managed care, Utilization Review, Case Management or five years nursing experience

• Relevant experience in UM process activities such as prior authorization or medical claims review

• Medical terminology, ICD-9/ICD-10 and CPT knowledge

• Proficiency with Microsoft Office applications

Preferred Qualifications:

• 2+ years practicing as a bedside nurse in an acute care setting

• Experience with specialty pharmacy

• Experience with Oncologic agents, Immunologic, or other specialty injectable highly desirable

• Exhibits professionalism and is courteous with all patients, physicians and co-workers

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: OptumCare is an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.