Nurse Reviewer

Role Overview

• conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines
• collaborating with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits
• working on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management
• partnering with more senior colleagues to complete non-routine reviews
• conducting medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment

Requirements

• Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background
• Current unrestricted RN license in applicable state(s) required
• BA/BS degree preferred
• Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred
• Previous utilization and/or quality management and/or call center experience preferred

Benefits

• merit increases
• paid holidays
• Paid Time Off
• incentive bonus programs
• medical benefits
• dental benefits
• vision benefits
• short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources