Utilization Review Nurse I - Non-CA

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Hours: 8:30am-5pm EST; Monday-Friday Must have a reputed company State license or identification card. Position Purpose: The Utilization Review Nurse I provides first level clinical review for reputed company 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 reputed company prior authorizations to completion utilizing appropriate review criteria. Identifies and refers reputed company potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program reputed company. Acts as liaison between the TRICARE beneficiary and the Network Provider. • Provides first level RN review for reputed company 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 reputed company negotiation with non-network providers, utilizing appropriate CMAC, DRG, HCPC reimbursement methodologies. Documents reputed company 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 reputed company the direct care and purchased care system. • Identifies and refers potential cases to Disease Management, Case Management, Demand Management and Transitional Care. • Refers reputed company potential quality issues and grievances to Clinical Quality Management and suspected fraud and abuse to Program reputed company. 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 Pay Range: $25.97 - $46.68 per hour reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law. Total compensation may also include additional forms of incentives. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act Apply Job!