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Utilization Review Nurse I

Fidelis Care Latham, New York, Getzville, New York

As a member of the Centene Medical Management/Health Services team, you’ll help innovate and execute strategies that redefine the industry standard for improving the lives and health of people. We’re a team of skilled physicians, nurses, pharmacists, social workers and health service experts who use our advanced clinical analytics to implement award winning programs, develop care, deliver partnerships, and work directly with our members to achieve outcomes that set us apart as industry leaders. Together, we’re transforming the health of communities, one person at a time.

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What does it take?

What are the qualities that will help you achieve success in this role at Centene?

Success Profile

  • Detail-oriented
  • Trustworthy
  • Personable
  • Quick-thinking
  • Multi-tasker
  • Good listener

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Our Medical Roles

Clinical & Nursing Opportunities at Centene

Our Clinical team is at the forefront of our purpose-driven work. Learn more about how you can help transform the health of our communities, one person at a time.

Overall Medical Management

A member of the Centene Medical Management team, we innovate and execute strategies that redefine the industry standard for improving the lives and health of people.

Concurrent Review Nurse

To ensure our members get the best quality of care, you’ll assess acute member health conditions, treatment and intervention options, and match them with providers, community and health plan resources.

Prior Authorization Nurse

You’ll ensure our members get the best quality services, assistive devices, and equipment to promote optimal health and independence in the community and help promote health and independence.

Care Manager

Working directly with members, interdisciplinary care team, providers and data analytics, you’ll identify member health risks and conditions and intervention and service options.

LTSS Program Specialist/Program Specialist Field Based

Working directly with our most vulnerable members, you’ll identify individual member health risks and opportunities to enhance independence, quality of life and community engagement.

Referral Specialist

You’ll use our data systems to directly assist providers, requesting services and treatments for our members.

Medical Director

To help support the individual needs of members and develop programs that address issues, you’ll review population health data, help design clinical programs, and develop care delivery partnerships.

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Responsibilities

Job ID 009ZR
Additional Locations Getzville,New York,US
Category Clinical & Nursing
Schedule Full-time
Description:
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.

  • 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.
  • Qualifications:

     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

    NYS licensed RN highly preferred.

     

     

     

     

    Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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    Quote

    “Centene is an exciting company to work for, the pace at which we’re growing allows numerous advancement opportunities. Also, we foster an environment that supports and offers numerous leadership growth opportunities.”

    - Esmeralda Baig, SVP Operations, Complex Care Products

    “I assisted with one of the Provider fairs in the community. Seeing how much we care for our community and our patients was very eye opening.”

    - Julie Boulch, Director, Business Implementation Health Plan Initiatives

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    Our Awards

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    “Flexibility is key. Centene is a company of change.”

    Ashley Collier

    Started as a Referral Specialist, now a Project Manager IV

    See Ashley's career path

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