Utilization Review III
Medica·Remote(United States)
Other
WFA Digital Insight
The demand for remote healthcare professionals has skyrocketed, with a 27% increase in job postings over the past year. Medica, a nonprofit health plan, is at the forefront of this trend. As a Utilization Review III, you'll play a crucial role in ensuring members receive necessary care, leveraging your clinical expertise to drive informed decisions. With the healthcare industry shifting towards digital transformation, professionals with strong clinical and digital skills are in high demand. Before applying, consider how your skills align with Medica's mission and values.
Job Description
About the Role
The Utilization Review III position is a critical component of Medica's healthcare team, responsible for reviewing, investigating, and resolving member and provider appeals and grievances. As a Utilization Review III, you will leverage your clinical expertise to evaluate the medical necessity, appropriateness of care, and benefit coverage for Medica members. Your work will involve collaborating with cross-functional teams, including clinical and non-clinical staff, to ensure that members receive the necessary care.The role entails conducting thorough clinical reviews, analyzing complex medical data, and making informed decisions that impact patient care. You will work in a fast-paced environment, navigating multiple priorities and deadlines while maintaining attention to detail and ensuring accuracy in your work.
What You Will Do
- Conduct comprehensive clinical reviews of member and provider appeals, evaluating medical necessity, appropriateness of care, and benefit coverage
- Investigate grievances by reviewing medical records, claims, and related documentation to resolve disputes and ensure member satisfaction
- Apply clinical expertise and knowledge of evidence-based criteria to make informed decisions regarding member care
- Collaborate with cross-functional teams, including clinical and non-clinical staff, to ensure seamless communication and coordination of care
- Analyze complex medical data to identify trends and areas for improvement, recommending changes to processes and procedures as needed
- Develop and maintain knowledge of clinical guidelines, regulatory requirements, and industry standards to ensure compliance and best practices
- Communicate complex clinical information to non-clinical stakeholders, including member and provider inquiries, in a clear and concise manner
- Participate in quality improvement initiatives, contributing to the development of policies, procedures, and educational materials
- Provide education and training to internal stakeholders on clinical topics, promoting a culture of clinical excellence
What We Are Looking For
- Current licensure as a registered nurse (RN), advanced practice registered nurse (APRN), or physician assistant (PA) in the United States
- Minimum 3-5 years of clinical experience in a healthcare setting, preferably in a utilization review or case management role
- Strong knowledge of clinical guidelines, evidence-based criteria, and regulatory requirements
- Excellent communication and interpersonal skills, with the ability to work effectively with diverse stakeholders
- Ability to work in a fast-paced environment, prioritizing multiple tasks and deadlines while maintaining attention to detail
- Strong analytical and problem-solving skills, with the ability to analyze complex data and make informed decisions
- Proficiency in electronic health records (EHRs) and other healthcare software applications
- Experience with remote work, digital communication tools, and collaboration platforms
Nice to Have
- Certification in utilization review, case management, or a related field
- Experience with data analysis and quality improvement initiatives
- Knowledge of healthcare reimbursement models and payment structures
- Familiarity with Medica's specific policies and procedures
Benefits and Perks
- Competitive salary and bonus structure
- Comprehensive benefits package, including medical, dental, and vision coverage
- Generous paid time off (PTO) and holiday schedule
- Paid volunteer time off and community service opportunities
- 401(k) contributions and retirement planning resources
- Caregiver services and support programs
- Opportunities for professional development and continuing education
How to Stand Out
- Develop a strong understanding of clinical guidelines, evidence-based criteria, and regulatory requirements to succeed in this role.
- Highlight your experience with electronic health records (EHRs) and other healthcare software applications in your application.
- Showcase your analytical and problem-solving skills by providing specific examples of complex data analysis and decision-making.
- Prepare to discuss your experience with remote work, digital communication tools, and collaboration platforms.
- Research Medica's specific policies and procedures to demonstrate your knowledge and interest in the company.
- Consider obtaining certification in utilization review, case management, or a related field to enhance your qualifications.
- Be prepared to discuss your experience with data analysis and quality improvement initiatives, and how you can apply these skills to drive positive change at Medica.
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