Longview, Texas
Edison, New Jersey
Corpus Christi, Texas
Posted: 31-Oct-24
Location: San Antonio, Texas
Salary: Open
Categories:
Internal Number: 143800976
WellMed, part of the Optum family of businesses, is seeking a LVN or LPN Pharmacy Utilization Management to join our team in San Antonio ,TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.
As a member of the Optum Care Delivery team, you’ll be an integral part of our vision to make healthcare better for everyone.
At Optum, you’ll have the clinical resources, data and support of a global organization behind you so you can help your patients live healthier lives. Here, you’ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career, and will empower you to live your best life at work and at home. Experience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country. Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while 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
In 2011, WellMed partnered with Optum to provide care to patients across Texas and Florida. WellMed is a network of doctors, specialists and other medical professionals that specialize in providing care for more than 1 million older adults with over 16,000 doctors’ offices. At WellMed our focus is simple. We’re innovators in preventative health care, striving to change the face of health care for seniors. WellMed has more than 22,000+ primary care physicians, hospitalists, specialists, and advanced practice clinicians who excel in caring for 900,000+ older adults. Together, we're making health care work better for everyone.
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.
