Utilization Review Nurse I (Non CA)
Company: Fidelis Care
Posted on: January 27, 2023
You could be the one who changes everything for our 26 million
members as a clinical professional on our Medical Management/Health
Services team. Centene is a diversified, national organization
offering competitive benefits including a fresh perspective on
Position Purpose: The Utilization Review Nurse I provides first
level clinical review for all outpatient and ancillary services
requiring authorization. Utilizes decision-making and
critical-thinking skills in the review and determination of
coverage for medically necessary health care services. Answers
Utilization Management directed telephone calls; managing them in a
professional and competent manner. Processes all prior
authorizations to completion utilizing appropriate review criteria.
Identifies and refers all potential quality issues to the Clinical
Quality Management Department, and suspected fraud and abuse cases
to Program Integrity. Acts as liaison between the TRICARE
beneficiary and the Network Provider.
--- Provides first level RN review for all outpatient and ancillary
prior authorization requests for medical appropriateness and
medical necessity using appropriate criteria, referring those
requests that fail review to the medical director for second level
review and determination. Completes data entry and correspondence
as necessary for each review.
--- Conducts rate negotiation with non-network providers, utilizing
appropriate CMAC, DRG, HCPC reimbursement methodologies. Documents
rate negotiation accurately for proper claims adjudication.
--- Acts as liaison between the TRICARE beneficiary and the
provider, facility and the MTF to utilize appropriate and cost
effective medical resources within the direct care and purchased
--- Identifies and refers potential cases to Disease Management,
Case Management, Demand Management and Transitional Care.
--- Refers all potential quality issues and grievances to Clinical
Quality Management and suspected fraud and abuse to Program
Education/Experience: Graduate of Nursing program; BSN desired or
Graduate in Clinical Psychology or Clinical Social Work. Three
years clinical experience in a health care environment; managed
care experience desired.
For Fidelis Care only: NYS RN, OT or PT license required
The salary range for NY is: $26.46 - $47.64 per hour
This information reflects the anticipated base salary range for
this position based on current national data. Minimums and maximums
may vary based on location. Actual pay will be adjusted based on an
individual's skills, experience, education, and other job-related
factors permitted by law.
Our Comprehensive Benefits Package: Flexible work solutions
including remote options, hybrid work schedules and dress
flexibility, Competitive pay, Paid time off including holidays,
Health insurance coverage for you and your dependents, 401(k) and
stock purchase plans, Tuition reimbursement and best-in-class
training and development.
Centene is an equal opportunity employer that is committed to
diversity, and values the ways in which we are different. All
qualified applicants will receive consideration for employment
without regard to race, color, religion, sex, sexual orientation,
gender identity, national origin, disability, veteran status, or
other characteristic protected by applicable law.
Keywords: Fidelis Care, New York , Utilization Review Nurse I (Non CA), Healthcare , Astoria, New York
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