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 16 consecutive years since the awards program began. It's a culture that embraces innovative ideas, strategic partnerships, and exemplary customer and provider experiences. 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.

UTILIZATION REVIEW SPECIALIST

The current hiring base salary range for this role is:

$84,436.00/year - $94,990.50/year

UCare anticipates paying within the above-references salary range for this position. The actual base salary offer for this position will be determined by a variety of components including but not limited to work experience, education, certifications, location of the role, internal equity, and other relevant factors.

LOCATION: Minneapolis, MN (Work from Home or Office for Your Day)

Position Description

As a Utilization Review (UR) Specialist, you will evaluate member-specific clinical information against standardized, evidence-based criteria to determine the medical necessity, appropriateness, and efficiency of healthcare services. You will be responsible for facilitating timely and accurate review processes, supporting member transitions of care, and referring members to appropriate clinical programs as needed. You will collaborate closely with healthcare providers, Medical Directors, and internal teams to ensure the delivery of high-quality, cost-effective care and compliance with regulatory requirements.

• 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 the medical necessity review process for services and/or review of acute care admissions and concurrent length of stay review.

• Collaborate with healthcare providers to assess member discharge needs, facilitate transitions of care, and ensure appropriate post-acute services are arranged.

• Refer cases to Case Management and other UCare clinical programs 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 and procedures.

• 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 all utilization review activities accurately and in accordance with organizational documentation protocols.

• Participate in on-call rotation for holidays and weekends as requested.

• Complete annual Inter-Rater Reliability (IRR) testing and other required regulatory or organizational training as requested.

• Collaborate with internal departments such as Claims, Provider Assistance Center, and Provider Relations/Network Management to support provider education and issue resolution as needed.

• Participate in cross-functional workgroups, committees, or performance improvement initiatives as assigned.

• Other projects and duties as assigned.

Education

Current and unrestricted Registered Nurse (RN) license in the state of Minnesota is required. Bachelor of Science in Nursing (BSN) is preferred. An Associate Degree in Nursing (ADN) with equivalent clinical experience may be considered in lieu of a BSN.

Required Experience

At least three years of direct clinical experience in one or more of the following settings: utilization review, case management, acute care, general medicine, surgical services, home health, or long-term care (e.g., nursing home).

Demonstrated experience in utilization review, case management, or discharge planning is strongly preferred. Familiarity with Medicaid and Medicare populations, regulations, and benefits is required.

Preferred Experience

Prior experience in Utilization Management within a health plan, managed care organization (MCO), or other payer environment.

Working knowledge of evidence-based medical necessity criteria (e.g., InterQual, MCG guidelines). Experience with state and federally funded healthcare programs, including regulatory compliance and authorization processes. Strong understanding of health plan operations and utilization review standards.

THE UCARE DIFFERENCE

The UCare difference is our people power - employees actively working on the behalf of our members to get them access to the health care they need. We value and respect each individual's ideas and contributions, and provide the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, and a myriad of volunteer activities. If you're looking for an inclusive environment that celebrates your people power, helps you build on your strengths and gives you the opportunity to truly make a difference, we invite you to apply.

BENEFIT ELIGIBLITY

Candidates hired into this position will also be eligible to participate in the following benefit programs: Paid Time Off; Earned Safe and Sick Time; Paid Holidays; Parental Leave; 401K program; medical, dental, vision, life insurance; short-term and long-term disability insurance; Flexible Spending Account and/or Health Savings Account, subject to meeting the eligibility requirements and terms and conditions of these programs.

This job posting should not be construed as an offer of employment with certain terms, nor should it be construed as a guaranteed minimum. UCare's policies and benefits are subject to change in UCare's sole discretion, consistent with applicable law.