Clinical Services Utilization Review Specialist
Health Care that Starts with You!
Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs. UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.
ABOUT UCAREAt UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities. WORKING AT UCAREWorking at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization - from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do. CLINICAL SERVICES UTILIZATION REVIEW SPECIALISTPosition DescriptionThe Utilization Review Specialist's primary responsibilities are to evaluate member specific clinical information against objective, standardized criteria to determine medical necessity, appropriateness and efficiency of specific services the organization has targeted for prior authorization. Specific duties and responsibilities include: ·Complete the continuum of utilization review processes within the established department turnaround times. This includes: initiate and complete first level medical necessity review; issue organization determination notifications including approvals, denials, terminations, and reductions; and routing service requests to medical directors' for physician review.·Review initial and concurrent requests for nursing home and skill nursing home admission and continued stay. ·Review initial acute inpatient rehabilitation and long term care acute admissions request and provide concurrent review for continued stay. Facilitate discharge planning with hospital and UCare or delegate case managers.·Refer cases to Care Management for potential case management activities based on identified member needs or utilization specific concerns.·Develop a comprehensive knowledge of member benefits for each product; understand, implement, and support the Evidence of Coverage, and follow organization policies as they relate to member benefits.·Provide medical necessity review for published authorization strategies, medical policies, review criteria, review standards, and regulatory requirements in the application of the utilization review process.·Understand and support the organization's provider network and contracts. ·Document review activities in accordance with professional nursing and established organizational standards. ·Provider medical necessity review of post service requests. ·Collaborate with claims, provider assistance center and provider relations and contracting in ad hoc provider education.·Participate in cross-departmental workgroups or teams as assigned.·Participate in Holiday Coverage. This includes being on-call over a holiday weekend, review incoming faxes for urgent requests, review and respond to the request, enter authorizations, respond to requests from CAG. ·Participate in and pass Annual Regulatory Inter-Rater Reliability testing. ·Other projects and duties as assigned.EducationRN or LPN with requisite experience. Current Minnesota nursing license requiredRequired ExperienceRN candidate with experience working with state or federally funded programs and one of the following:•3 years as staff or charge nurse in hospital, preferably med/surg adults or•2 years as staff or charge nurse in hospital and 2-5 yrs long term care experience in Medicare nurse role or•5 years long term care experience and 2-3 years home care nursing or•2 years as staff or charge nurse in hospital and 2-3 years home care nursing. LPN candidate with experience working with state or federally funded programs and at least one of the following:•5 years long term care experience or•3 years as staff nurse in hospital, preferably med/surg adults or•2 years as staff or charge nurse in hospital and 2-5 yrs long term care experience or•5 years long term care experience and 2-3 years home care nursing or•2 years as staff or charge nurse in hospital and 2-3 years home care nursingPreferred ExperienceRN candidate with 2 years experience in utilization review and/or case management. LPN with 5 years long term care experience in a Medicare and/or MDS role. Knowledge of utilization review standards and experience working with state and federally funded programs. Experience in an HMO or MCO highly desirable.
THE UCARE DIFFERENCEUCare is proud to be a recognized Star Tribune Top Workplace for the 9th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply. As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.
Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers.
At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.