Utilization Review Nurse I-OutpatientGetzville, New York Apply Now Job ID 009TL Additional Locations New York,New York,US Category Health Insurance Operations Organization Fidelis Care Schedule Full-time
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.
Education/Experience: Graduate of Nursing program; BSN desired or Graduate in Occupational Therapy or Physical Therapy. Three years clinical experience in a health care environment; managed care experience desired.
License: NYS RN, OT or PT license required
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