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 appropriately, 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, then successfully perform live ODAG reviews with auditors and respond to desk review requests. Provide clinical input to the Review team and Referral Specialists, identify operational improvements, and communicate effectively with patients, staff, and external providers. Maintain strict confidentiality, adhere to HIPAA, 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
- One-year acute care experience
- 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
- Skilled in use of computer/EMR systems
- Knowledge of Word processing software
- Knowledge of spreadsheet software
- Knowledge of Internet
- Knowledge of database software
Desired Qualifications
- Bilingual English/ Spanish fluency
- Prefer BS in Nursing
- Experience in a clinic, doctor's office or hospital with a minimum of one-year acute care experience
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