Utilization Review Nurse III

Medica; United States; Remote; USD 68,000 - 118,000; Full time

Job summary

Medica seeks a Utilization Review Nurse to manage prior authorization requests and assess case trends for policy improvements. This fully remote role requires strong clinical judgment and an active RN license, with a competitive salary range based on experience and qualifications.

Benefits

Generous total rewards package

Medical, dental, and vision benefits

PTO and Holidays

Paid volunteer time off

401K contributions

Qualifications

• 5+ years clinical experience required.
• Previous utilization management experience preferred.
• Active RN license is necessary.

Responsibilities

• Review and document prior authorization requests.
• Analyze trends in case reviews and recommend policy revisions.
• Interface with members, providers, and internal departments.

Skills

Clinical assessment skills

Critical thinking

Self-motivation

Organization skills

Technology-savvy

Education

Associate’s or Bachelor’s degree in Nursing

Job description

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 and will work remotely 100% of the time. To be eligible for consideration, candidates must have a primary home address located within any state where Medica is registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MD, ME, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI.

The full salary range for this position is $68,800 - $118,000. 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.

We are an Equal Opportunity 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.

Qualifications

Skills

Behaviors

:

Motivations

:

Education

Experience

Licenses & Certifications

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.