Utilization Review Specialist

Minneapolis, Minnesota
Apr 12, 2022
May 20, 2022
Employment Status
Full Time
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 600,000 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.


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.




UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.


Working at UCare is more than 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. Employees join UCare and stay because of the opportunity to have a purpose-driven job.

Our strong culture has established UCare as a Star Tribune Top 150 Workplace for 12 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.


Work Location: Work from home, or hybrid (in the office 3 or more days per week)

The health and safety of our employees, members, providers, and our community is our highest priority. Therefore, all new employees are expected to be fully vaccinated against COVID-19 prior to starting at UCare, subject to limited exceptions such as for a sincerely held religious belief or for medical reasons.

Position Description

This position is responsible 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. You will collaborate with peers to identify care level needs, authorization for services, and refer members to care management, as appropriate.

• Complete the continuum of the utilization review processes within the established department turnaround times including: first level medical necessity review, consultation with Medical Directors and/or healthcare providers, and/or facilitate peer to peer discussions when applicable.

• Review medical records as part of prior authorization review for services and/or review of acute care admissions and concurrent length of stay review.

• Partner with healthcare providers to assess member's discharge needs for post-acute care, actively participate to assist with transition of care, and to establish care support.

• Refer cases to Case 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.

• Participate in Holiday On-Call Coverage.

• Participate in and pass Annual Regulatory Inter-Rater Reliability testing.

• Evaluates potential denials or payment issues and initiates communication with Medical Directors and/or healthcare providers regarding next steps.

• 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.

• Other projects and duties as assigned.


Registered Nurse, BSN preferred. Current and unrestricted Minnesota nursing license required.

Required Experience

At least two years acute care clinical experience or a minimum of three to five years' experience in a post-acute care setting.

Preferred Experience

Utilization review and/or case management experience. Knowledge of utilization review standards, decision making tools (ie: InterQual or MCG), and experience working with state and federally funded programs. Health Plan experience preferred.


The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, 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.

JOB POST DATE: 04/11/2022

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