- Complete the continuum of the utilization review processes within the established department turnaround times including: first level medical necessity review, consultation with Medical Directors and/or healthcare providers, and/or facilitate peer to peer discussions when applicable.
- Review medical records as part of prior authorization review for services and/or review of acute care admissions and concurrent length of stay review.
- Partner with healthcare providers to assess member's discharge needs for post-acute care, actively participate to assist with transition of care, and to establish care support.
- Refer cases to Case Management for potential case management activities based on identified member needs or utilization specific concerns.
- Develop a comprehensive knowledge of member benefits for each product; understand, implement, and support the Evidence of Coverage, and follow organization policies as they relate to member benefits.
- Provide medical necessity review for published authorization strategies, medical policies, review criteria, review standards, and regulatory requirements in the application of the utilization review process.
- Understand and support the organization's provider network and contracts.
- Document review activities in accordance with professional nursing and established organizational standards.
- Participate in Holiday On-Call Coverage and monthly late nurse rotation.
- Participate in and pass Annual Regulatory Inter-Rater Reliability testing.
- Collaborate with claims, provider assistance center, and provider relations and contracting in ad hoc provider education.
- Participate in cross-departmental workgroups or teams as assigned.
- Other projects and duties as assigned.
-
Contract Review Specialist
3 weeks ago
DC Group Minneapolis, United StatesDo you want to be part of a rapidly growing company that was voted one of Star Tribune's Top 200 workplaces in 2023? · Become part of a family owned, local business with a multi-national footprint and proven track record as an innovator · DC Group, Inc., headquartered in Minnea ...
-
Konkordia Phoenix PLC, Inc. Minneapolis, United StatesJob Description · Job DescriptionSalary: · Job title: Claim Recovery and Litigation Review Specialist · Department: Recovery Operations – Integrated Legal Services · Position type: Full Time · Compensation: Salary plus Benefits · Location: Remote (MN, TX, FL) · COMPANY OVERVIE ...
-
Document Review Specialist
1 week ago
Insight Global Saint Paul, United StatesJob Description · Job DescriptionMust Have Qualifications: · High school diploma or equivalent with Confident, Go Getter Attitude and Drive - One to three years of related experience in an office setting (longevity) · Can lift 30-40Ibs · Excel (tech savvy, used in previous roles) ...
-
Senior Risk Asset Review Examination Specialist
1 month ago
Wells Fargo MINNEAPOLIS, United States Paid WorkAbout this role: · Wells Fargo is seeking a Principal Examiner - Senior Risk Asset Review Specialist in Credit Risk as part of Corporate Risk. Learn more about the career areas and lines of business at . Credit Risk, which independently oversees the management of credit risk exp ...
-
HealthPartners Bloomington, United States Regular, Full timeHealthPartners is hiring for an RN Clinical Review Prior Authorization Utilization Management Specialist. This position is responsible for accurate application of HealthPartners evidence-based coverage criteria in alignment with member benefit plan. Appropriate management of Heal ...
-
FA-POST Billing
1 week ago
Addison Group Minneapolis, United States Contract To HireJob Title: Billing & Collections Specialist · Location: Minneapolis, MN · Pay Rate: Up to $60000 / year dependent on applicable experience · Internal Job ID: 575515 · Addison Group has a client who is looking for a Billing & Collections Specialist Our client is located in Minneap ...
-
Strategic Sourcing Specialist
3 weeks ago
eTeam Minneapolis, United StatesJob Title: Strategic Sourcing Specialist · Duration: 6+ Months Contract, FTE Conversion Possible · Location: Minneapolis MN 55402 · HYBRID: 3 DAYS PER WEEK IN OFFICE REQUIRED · Pay Range: $30-$40/hr. on w2, without benefits · Job Description: · Education requirements: College De ...
-
Copywriting and Content Specialist
2 weeks ago
Dahl Consulting Plymouth, United StatesDahl Consulting is currently partnering with a leading company in the powersports industry. We work one-on-one with great candidates to help connect them with local employment opportunities. This company is hiring a Copywriting and Content Specialist for a contract position Inter ...
-
Non - IT Project Manager/Contracts Specialist
2 weeks ago
Pyramid Consulting, Inc Minneapolis, United StatesImmediate need for a talented Non - IT Project Manager/Contracts Specialist. This is a 06+ Months Contract opportunity with long-term potential and is located in Minneapolis, MN(Onsite). Please review the job description below and contact me ASAP if you are interested. · Job ID: ...
-
Risk Management Specialist
2 weeks ago
Mindlance Minneapolis, United StatesTitle: Business Execution Consultant / Risk Management Specialist · Location: Minneapolis, MN · Term: 06 months (Possible Contract to Hire) · Grow your career as a Business Execution Consultant with an innovative global bank. 06+ months contract opportunity (with a strong chance ...
-
Customer Service Specialist
3 weeks ago
Recruiting Industry Specific Experts, LLC Minneapolis, United StatesThe Client Service Specialist will provide client service and operational support to advisors and clients. This team player will be responsible for updating and maintaining the CRM, client files, reports, and other financial documentation. They will also play an essential role in ...
-
Coding Specialist
2 weeks ago
University of Minnesota Physicians Minneapolis, United States Full timeWhy M Physicians? Regardless of role, we recognize that every member of our team is vital The Coding Specialist is responsible for the accurate and timely coding of complex services. This role is responsible for ensuring accurate diagnoses, procedure codes and other specified dat ...
-
Payroll Specialist
2 days ago
HireTalent - Diversity Staffing & Recruiting Firm Minneapolis, United StatesWe're Hiring: Payroll Specialist - Payroll Operations · Join a leading American utility company headquartered in Minneapolis, MN, serving over 3.7 million electric and 2.1 million natural gas customers across eight states. · Scope of Work/Project: As a Payroll Specialist , you'll ...
-
Construction Site Operations Specialist
3 weeks ago
AEC Resources, Inc. Richfield, United StatesJoin our team as a Construction Site Operations Specialist for commercial electrical installations · Do you have an interest in electrical system construction within commercial buildings? We are hiring a proactive Construction Site Operations Specialist to oversee the implementat ...
-
Prin AI/Data Science Engineer
1 week ago
ATR International Minneapolis, United StatesJob Description: · We are seeking a Prin AI/Data Science Engineer for a very important client This request is for AMI (Analytics Manufacturing Imaging) Platform Responsibilities may include the following and other duties may be assigned In new product design roles: develops and ...
-
NorthPoint Payroll Specialist
2 weeks ago
Hennepin County Minneapolis, United StatesDescription · NorthPoint Health & Wellness Center, a state-of-the-art multicultural, community-based medical and dental clinic is seeking someone who enjoys working with the public, has strong communication skills, and a desire to help others while serving the community to join ...
-
Senior Strategic Sourcing Specialist
3 weeks ago
INSPYR Solutions Minneapolis, United StatesTitle: Strategic Sourcing Specialist · Location: Minneapolis MN (3 days on site) · Duration: 6+ months (Potential to convert FTE) · Compensation: $38-42/hr. · Work Requirements: US Citizen, GC Holders or Authorized to Work in the U.S. · If interested, please contact Margot Parson ...
-
Contracts Specialist
3 weeks ago
Adams & Martin Group Minneapolis, United StatesAdams & Martin Group is seeking a Contracts Specialist to join a growing oranization in the South Metro. This is a direct hire opportunity with a hybrid work model. · Responsiblities: · Manage the review and processing of standard contracts, ensuring final execution and proper d ...
-
Senior Title Specialist Hybrid
2 weeks ago
EDF Renewables North America Minneapolis, Minnesota, United States PermanentScope of Position: · EDF Renewables North America is a market-leading independent power producer and service provider with over 35 years of experience. We deliver grid-scale power: wind (onshore and offshore), solar photovoltaic, and storage projects; distribution-scale power: so ...
-
Talent Acquisition Specialist
2 weeks ago
AppleOne Employment Services Minneapolis, United StatesWe are looking for a Talent Aquisition Specialist in Minneapolis, MN 2-5 years of experience in manufacturing. · Direct hire role · Salary: up to $75,000 plus commission · The HR and Talent Acquisition Specialist performs talent acquisition duties to attract and hire new employee ...
Utilization Review Specialist - Minneapolis, United States - UCare Minnesota
Description
ABOUT UCARE
UCare offers Medicare, Medicaid, Individual and Family health plans - powered by the hardest working people in the industry. Our people powered teams de-complicate, advocate and always go the extra mile to help our members. We serve with integrity, compassion and commitment to do right by members, providers and government partners. Above all, we come to work excited to provide members a path for the best health of their lives.
WORKING AT UCARE
Working at UCare is more than a career; it's a mission.
A mission that defines us as professionals, unites us as an organization and shapes how we interact with our members and each other.
Employees join UCare and stay because of the opportunity to have a purpose-driven job.
Our strong culture has established UCare as a Star Tribune Top 200 Workplace for 14 consecutive years since the awards program began.
Working at UCare is being a part of a people powered team dedicated to making a real difference in the lives of our members and communities.
Position Description
As a Utilization Review (UR) Specialist, you will be responsible to evaluate member specific clinical information against objective, standardized criteria to determine medical necessity, appropriateness, and efficiency of specific services the organization has targeted for prior authorization.
