Nurse Reviewer 1
Core
Conducts preauthorization, out-of-network, and appropriateness reviews for diagnostic imaging services to ensure quality member outcomes and optimize benefits.
Role type
Entry-level licensed nurse reviewer (utilization management)
Builds
Medical necessity determinations for diagnostic imaging preauthorizations
Domain
Healthcare / Utilization Management / Diagnostic Imaging
Deliverable
client delivery
Required skills
Unrestricted RN license, 3 years clinical nursing experience (ambulatory/hospital) OR 1 year utilization/medical/quality management/call center experience, Medical necessity screening, Clinical guidelines application, Provider communication, Documentation standards
Preferred skills
BA/BS degree, Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, Managed health care plan knowledge (HMO, PPO, POS), Previous utilization/quality management/call center experience
Technologies
ICD-10, CPT-4
Responsibilities
Conduct initial medical necessity clinical screening for preauthorization requests, Review exception preauthorization requests for out-of-network services, Notify ordering physicians or providers of preauthorization decisions, Follow up to obtain additional clinical information, Ensure proper documentation and provider communication per department standards
Seniority
Entry-level, non-management, non-exempt