LVN?/LPN Pharmacy Utilization Management
Posted 2025-03-14Position: LVN/LPN Pharmacy Utilization Management San Antonio Texas
Well Med, part of the Optum family of businesses, is seeking a LVN or LPN Pharmacy Utilization Management to join our team in San Antonio, TX. Optum is a clinician-led care organization that is changing the way clinicians work and live.
As a member of the Optum Care Delivery team, you?ll be an integral part of our vision to make healthcare better for everyone.
At Optum, you?ll have the clinical resources, data, and support of a global organization behind you so you can help your patients live healthier lives. Here, you?ll work alongside talented peers in a collaborative environment that is guided by diversity and inclusion while driving towards the Quadruple Aim. We believe you deserve an exceptional career and will empower you to live your best life at work and erience the fulfillment of advancing the health of your community with the excitement of contributing new practice ideas and initiatives that could help improve care for millions of patients across the country.
Because together, we have the power to make health care better for everyone. Join us and discover how rewarding medicine can be while Caring. Connecting. Growing together.
The Utilization Management Nurse for Medical Management Pharmacy is responsible for utilization review and the coordination of members Medicare Part B medication through UM Pharmacy staff, Medical Directors, and various other departments. This position will perform Utilization Reviews of specialty drugs appropriateness as applicable to Medicare Part B benefit.
Primary Responsibilities: ? Collaborates with the providers to recommend policies, procedures, and standards which affect the care of the member. ? Provides summary clinical and ancillary information to Clinical Pharmacist and Medical Director for review and decision making for targeted Part B medications. ? Gathers additional information and research requests for cases requiring presentation to medical director and/or Clinical Pharmacist. ? Generates referral entries accurately identifying the covered services authorized including ICD-9/ICD-10 coding, service groups, and appropriate medical terminology in text. ? Discusses patient care specifics with peers or providers involved in overall patient care and benefits. ? Advocates with physicians and others for appropriate decisions regarding patient health and welfare (e.g., care and service coverage, safety). ? Answers patient questions regarding care and benefits. ? Researches and identifies information needed to perform assessment, respond to questions, or make recommendations. ? Applies knowledge of pharmacological and clinical treatment protocol to determine appropriateness of care and instruct patients as needed. ? Demonstrates understanding necessary to assess, review, and apply criteria (e.g., Milliman guidelines, CMS criteria, medical policy, Well Med Guidelines, plan-specific criteria). ? Demonstrates knowledge of process flow of UM including prior authorization, concurrent authorization, and/or clinical appeal and grievance reviews. ? Solves problems by gathering and/or reviewing facts and selecting the best solution from identified alternatives. ? Performs all other related duties as assigned.
This is an office-based/Hybrid position located at our office near IH 10 W, San Antonio, TX. The position requires rotating Saturday and holiday shifts (shift differential pay offered).
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
#J-18808-Ljbffr
For more such jobs please click here!