Case Manager Utilization Review Nurse Jobs in Rosharon, TX

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40 locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.  

The Utilization Review LVN nurse will perform documentation review for medical necessity and benefit correlation of requested medical and surgical procedures, services and admissions for HMO, PPO and POS products.  The UR LVN nurse will serve as facilitator of communication with clinic, payor and other customers.

Primary Responsibilities:

• Data entry of all UR requests into the Kelsey-Seybold data system
• Verifies eligibility
• Obtains benefit interpretation from insurance company
• Reviews request and chart to determine medical necessity by using internal criteria
• Approves request or defers to insurance review and assists with MD review
• Communicates with respective payor to obtain pre-certification authorization
• Serves as resource to physicians, staff and patients regarding review process
• Clarifies UR request discrepancies with office submitting or insurance company
• Other duties as assigned

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:

• Licensed Vocational Nurse
• CEU requirement
• TX LVN license
• 2 years of utilization review experience at heath plan, ACO, IPA, or provider group OR 3 years of diverse clinical experience, including acute care or similar care
• Good organization and communication skills
• HMO, PPO and POS insurance knowledge
• Valid Driver's license

Preferred Qualifications:

• Computer and Coding experience

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The hourly pay for this role will range from $20.00 to $36.00 per hour based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.