Nurse Reviewer I
Core
Conducts preauthorization, out-of-network, and appropriateness reviews for diagnostic imaging services to ensure medical necessity and optimize member benefits.
Role type
Entry-level clinical nurse reviewer (utilization management)
Builds
Preauthorization decisions and clinical screenings for diagnostic imaging
Domain
Healthcare / Utilization Management / Diagnostic Imaging
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical nursing experience, medical necessity assessment, provider communication, documentation standards, policy/guideline application
Preferred skills
Utilization management guidelines, ICD-9/CPT-4 coding, managed health care plans (HMO/PPO/POS), quality management, call center experience
Technologies
None explicitly stated
Responsibilities
Conduct initial medical necessity clinical screenings 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
Junior, entry-level IC