Medica is a nonprofit health plan with more than a million members that serves
communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver
personalized health care experiences and partner closely with providers to
ensure members are genuinely cared for.
We're a team that owns our work with accountability, makes data-driven
decisions, embraces continuous learning, and celebrates collaboration — because
success is a team sport. It's our mission to be there in the moments that matter
most for our members and employees. Join us in creating a community of connected
care, where coordinated, quality service is the norm and every member feels
valued.
The Utilization Review RN will review and document member case history in
compliance with policies and procedures for approval of member coverage. The
role requires attention to detail and use of clinical judgment to determine
clinical benefits. LPN or RN Required. Perform other duties assigned.
Key Responsibilities:
Medica’s Utilization Review Nurses are responsible for reviewing and
documenting prior authorization requests and member case history in
compliance with policies and procedures for approval of member coverage.
Medica’s Utilization Review Nurses are also responsible for the analysis of
trends through feedback, which may be identified through the review of cases,
and for addressing these issues by recommending revision of medical policies
and utilization management and/or clinical appeals policies.
Utilization review activities require interfacing with members, providers,
clinics, medical directors, intake staff, case managers and other departments
internally within Medica.
Required Qualifications:
Associate's or Bachelor's degree or equivalent experience in related field
5 years of work experience beyond degree
RN license
Preferred Qualifications:
Experience with appeals strongly preferred
Utilization Management experience
Knowledge surrounding regulatory requirements (i.e. CMS and NCQA) specific to
UM processes
Self-motivated, autonomous worker with the ability to work independently but
also collaboratively within a team environment
Detail-oriented with strong organization skills
Technology-savvy; ability to work within multiple computer applications
Demonstrated clinical assessment skills with the ability to think critically
and make evidence-based decisions
Certifications/Licensure
Active, unrestricted RN license required
This position is a Remote role. To be eligible for consideration, candidates
must have a primary home address located within any state where Medica is
registered as an employer - AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE,
OK, SD, TN, TX, VA, WI
The full salary grade for this position is $70,200 - $120,400. While the full
salary grade is provided, the typical hiring salary range for this role is
expected to be between $70,200 - $105,315. Annual salary range placement will
depend on a variety of factors including, but not limited to, education, work
experience, applicable certifications and/or licensure, the position's scope and
responsibility, internal pay equity and external market salary data. In
addition to compensation, Medica offers a generous total rewards package that
includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time
off, 401K contributions, caregiver services and many other benefits to support
our employees.
The compensation and benefits information is provided as of the date of this
posting. Medica’s compensation and benefits are subject to change at any time,
with or without notice, subject to applicable law.
Eligibility to work in the US: Medica does not offer work visa sponsorship for
this role. All candidates must be legally authorized to work in the United
States at the time of application. Employment is contingent on verification of
identity and eligibility to work in the United States.
We are an Equal Opportunity employer, where all qualified candidates receive
consideration for employment indiscriminate of race, religion, ethnicity,
national origin, citizenship, gender, gender identity, sexual orientation, age,
veteran status, disability, genetic information, or any other protected
characteristic.