Opportunities at WellMed , part of the Optum family of businesses. We believe all patients are entitled to the highest level of medical care. Here, you will join a team who shares your passion for helping people achieve better health. With opportunities for physicians, clinical staff and non-patient-facing roles, you can make a difference with us as you discover the meaning behind *Caring. Connecting. Growing together.  *

　　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

　　This is an office-based/Hybrid position located at our office near IH 10 W, San Antonio, TX. The position requires rotating Saturday and holiday shifts (shift differential 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:

　　High School diploma or GED

　　Current LVN license in state of Texas

　　2+ years of experience in managed care setting

　　Preferred Qualifications:

　　4+ years of clinical experience in primary care physician office or hospital setting

　　2+ years of experience in managed care or referral management position

　　Experience with specialty pharmacy

　　Experience with Oncologic agents, Immunologic, or other specialty injectable

　　*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

　　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: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer 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.

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