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)
Positions in this function require various nurse licensure and certification based on role and grade level. Licensure includes RN or LPN/LVN, depending on grade level, with current unrestricted licensure in applicable state. LPN/LVN roles work under the direct supervision of an RN or MD. Function is responsible for utilization management which includes Concurrent Review (on-site or telephonic Inpatient Care Management). Performs reviews of current inpatient services. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. *Employees in jobs labeled with ‘SCA’ must support a government Service Contract Act (SCA) agreement.
Reviews the work of others
Develops innovative approaches
Sought out as expert
Serves as a leader/ mentor
Requires current unrestricted RN licensure in applicable state
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.
Bachelor of Science in Nursing, Healthcare Administration or a related field
Current unrestricted Registered Nurse (RN) with current license in Texas, or other participating States
5+ years of progressively responsible healthcare experience to include experience in a managed care setting, and/or hospital settings, and/or physician practice setting
3+ years of experience in managed care with at least two years of Utilization Management experience
Knowledge and experience with CMS, URAC and NCQA
Knowledge of Medicare and Medicaid benefit products including applicable state regulations
Demonstrate knowledge of computer functionality navigation and proficiency with Microsoft Office applications required (e.g., Windows, Microsoft Office applications including Microsoft Word and Microsoft Excel)
Demonstrate knowledge of specific software applications associated with the job function (e.g., navigation of relevant computer applications or systems, intranet databases, records management or claims databases)
Health Plan or MSO quality, audit or compliance experience
Solid knowledge of Medicare and TDI regulatory standards
Auditing, training or leadership experience
Solid knowledge of process flow of UM including prior authorization and/or clinical appeals and grievance reviews
Full COVID-19 vaccination is an essential job function of this role. Candidates located in states that mandate COVID-19 booster doses must also comply with those state requirements. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination, and boosters when applicable, prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation.
To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles and locations require full COVID-19 vaccination, including boosters, as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment
Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)
WellMed was founded in 1990 with a vision of being a physician-led company that could change the face of healthcare delivery for seniors. Through the WellMed Care Model, we specialize in helping our patients stay healthy by providing the care they need from doctors who care about them. We partner with multiple Medicare Advantage health plans in Texas and Florida and look forward to continuing growth.
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.