UM Nurse
On-siteSan Antonio, Texas, United States
Job Summary
Summarize medical records for physician medical necessity reviews and compose denial letters per CMS standards. Apply evidence-based criteria to reviews, document findings, and perform daily authorization oversight to ensure proper referral documentation in EZ Cap and EMR. Pull, validate, and submit ODAG and Part C reports to health plans, while conducting live ODAG reviews with auditors and responding to desk review requests within defined timelines. Identify operational improvement opportunities and collaborate with the UM team and provider PODs. Maintain strict confidentiality, adhere to customer service expectations, and participate in educational programs and annual policy reviews.
Required Qualifications
- Active, unencumbered Registered Nurse
- Associate degree
- State-licensed practical nurse with one year of LVN and clinic experience
- BS in Nursing
- At least 5 years' experience in Managed Care
- At least 5 years' experience in Utilization Management
- Minimum of one-year acute care experience
- All licenses and certifications current and in good standing
- Skilled in use of computer/EMR systems
- Knowledge of Word processing software
- Knowledge of spreadsheet software
- Knowledge of Internet
- Knowledge of database software
- Manual dexterity
- Ability to sit
- Ability to stand
- Ability to stoop
- Ability to reach
- Ability to kneel
- Ability to crouch
- Ability to bend
- Ability to walk
- Ability to lift up to 40 lbs without assistance
- Close vision
- Ability to adjust focus
- Ability to work efficiently under pressure
Desired Qualifications
- Bilingual English/ Spanish fluency
- Experience in a clinic, doctor's office or hospital with a minimum of one-year acute care experience
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