Utilization Review RN III

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. 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 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.