Job Details
Position: Outpatient Utilization Review Nurse
100% Remote
Duration: Ends December 2024
Hours: 9-530 (PST)
Our client is looking for a Utilization Review Nurse to provide first level clinical review or all outpatient and ancillary services requiring authorization.
Day to Day:
- 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 care system.
- 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 Integrity.
Requirements:
- Bachelor of Nursing degree or related
- MUST HAVE a valid RN license in the state they reside in
- 3+ years of Nursing exp., particularly outpatient nursing experience
- Experience working at a Payer
- Prior-Authorization experience
Soft Skills:
- Demonstrates a high level of accuracy, even under pressure
- Friendly and service-oriented.
- Possesses intermediate flexibility to work in a fast-paced, dynamic environment.