LVN/LPN Pharmacy Utilization Management San Antonio Texas

About the position

The LVN/LPN Pharmacy Utilization Management position at WellMed in San Antonio, Texas, is designed for a licensed vocational nurse or licensed practical nurse to engage in utilization review and coordination of Medicare Part B medications. This role is integral to the Optum Care Delivery team, focusing on improving healthcare delivery through collaboration with providers and clinical staff. The position emphasizes the importance of patient advocacy, clinical decision-making, and adherence to established medical guidelines.

Responsibilities

• Collaborates with providers to recommend policies, procedures, and standards affecting member care.
• 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 covered services authorized, including ICD-9/ICD-10 coding and appropriate medical terminology.
• 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.
• Answers patient questions regarding care and benefits.
• Researches and identifies information needed to perform assessments or make recommendations.
• Demonstrates understanding necessary to assess, review, and apply criteria for utilization management.
• Solves problems by gathering and reviewing facts and selecting the best solution from identified alternatives.
• Performs all other related duties as assigned.

Requirements

• High School diploma or GED
• Current LVN license in the state of Texas
• 2+ years of experience in a managed care setting.

Nice-to-haves

• 4+ years of clinical experience in a primary care physician office or hospital setting
• 2+ years of experience in managed care or referral management position
• Experience with specialty pharmacy
• Experience with Oncologic agents, Immunologic, or other specialty injectables.

Benefits

• Competitive salary
• Shift differential pay for rotating Saturday and holiday shifts
• Opportunities for professional development and career advancement