Utilization Review RN III

About Medica

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.

Responsibilities

• Review and document prior authorization requests and member case history in compliance with policies and procedures for approval of member coverage.
• Analyze trends through feedback identified during case reviews and recommend revisions to medical policies and utilization management policies.
• Interface with members, providers, clinics, medical directors, intake staff, case managers, and other internal departments at Medica.
• Use clinical judgment to determine clinical benefits with attention to detail.
• Perform other duties as assigned.

Requirements

• Associate's or Bachelor's degree or equivalent experience in a related field.
• 5 years of work experience beyond degree.
• Active, unrestricted RN license.

Preferred Qualifications

• Experience with appeals.
• Utilization Management experience.
• Knowledge of regulatory requirements (e.g., CMS and NCQA) specific to UM processes.
• Self-motivated, autonomous worker with the ability to work independently and collaboratively within a team environment.
• Detail-oriented with strong organizational 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.

Pay

The full salary grade for this position is $70,200 - $120,400. The typical hiring salary range is expected to be between $70,200 - $105,315. Annual salary range placement will depend on factors including education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity, and external market salary data.

Benefits

• Competitive medical, dental, and vision coverage.
• Paid time off (PTO) and holidays.
• Paid volunteer time off.
• 401K contributions.
• Caregiver services and many other benefits to support employees.

Schedule

This position is a remote role. 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, or WI.

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.