Utilization Review Nurse I

Location: New York-NYC - Rego Park
Duration: Full Time
Job ID: 1127314 (21620317)
Category: Risk Management RN Job
Company: ProEnlist
Contact: Kat Forester
Job Posted: 01/26/21

Utilization Review Nurse I - 1127314 (21620317)

About the Company: 
A Fortune 500 company, is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government sponsored healthcare programs, focusing on underinsured and uninsured individuals.  Many receive benefits provided under Medicaid, including the State Children's Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long Term Care (LTC), in addition to other state-sponsored/hybrid programs, and Medicare (Special Needs Plans).  

The Company operates local health plans and offers a range of health insurance solutions.  It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, correctional healthcare services, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and telehealth services.


Position Overview:
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. 


Responsibilities:

  • 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.

 


Benefits: 
The company offers more than just medical insurance. They pay most of your benefits costs and in some cases – they pay 100 percent. Most of the benefits not covered by the company are paid with pre-tax payroll deductions. 

  • Health insurance
  • Dental insurance
  • Vision insurance
  • Flexible spending accounts (includes health care, dependent care mass transit reimbursement)
  • Short- and long-term disability insurance
  • Basic Life insurance
  • Supplemental AD&D
  • Supplemental life insurance
  • Wellness Program
  • 401(k) retirement with company match
  • Employee stock purchase plan
  • Vacation, Personal and Sick time
  • Paid Company Holidays
  • Employee Assistance Program (EAP)
  • Training and Learning Opportunities
  • Tuition Reimbursement/Educational Assistance
  • Service Awards
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location


Qualifications:
Education/Experience:

  • Graduate of Nursing program; BSN desired. or Graduate in Occupational Therapy or Physical Therapy.
  • 3 years clinical experience in a health care environment; managed care experience desired.


License: NYS RN, OT or PT license required.