Utilization Review Nurse II
Posted on: 20 Mar 2021
Detroit, MI
Job Description
Position Purpose:
The Utilization Review Nurse II leads the daily activities of the Utilization Management RN I positions. Participates with the manager in the selection process for open UM RN positions. Conducts routine audits of the UM RN I job duties and oversees workload balancing. Provides first level clinical review for 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 CQ& Department, and suspected fraud and abuse cases to Program Integrity. Serves as liaison between the TRICARE beneficiary and the Network Provider.
* Functions in a lead UM RN role and performs auditing functions for the Utilization Management RN I.
* Provides advanced level of benefit and clinical analysis according to TRICARE coverage and medical review guidelines.
* Participates in the training and orientation of new associates in the UM RN I and II roles. Serves as a mentor/preceptor during the first six months of orientation.
* Conducts rate negotiation with non-network providers, utilizing appropriate CMAC, DRG, and HCPC reimbursement methodologies. Documents rate negotiation accurately for proper claims adjudication.
* Participates with the Manager in the interview process for open Utilization Management RN positions.
Education/Experience:
Graduate of Nursing program; BSN desired or Graduate in Clinical Psychology or Clinical Social Work. Three to five years clinical experience in a health care environment, with supervisory experience; Managed care experience desired
License/Certification:
Current valid and unrestricted state license/certification for Registered Nurse, Clinical Psychologist, or Licensed Clinical Social Worker license. Valid state drivers license.
For Fidelis Care only: NYS RN, OT or PT license required.
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.
Centene
St Louis, MO
Centene Corporation operates as a diversified and multi-national healthcare enterprise that provides programs and services to under-insured and uninsured individuals in the United States. The company’s Managed Care segment offers health plan coverage to individuals through government subsidized programs, including Medicaid, the State children’s health insurance program, long-term services and support, foster care, and medicare-medicaid plans, which covers dually eligible individuals, as well as aged, blind, or disabled programs. Its health plans include primary and specialty physician care, inpatient and outpatient hospital care, emergency and urgent care, prenatal care, laboratory and X-ray, home-based primary care, transportation assistance, vision care, dental care, telehealth, immunization, specialty pharmacy, therapy, social work, nurse advisory, and care coordination services, as well as prescriptions, limited over-the-counter drugs, medical equipment, and behavioral health and abuse services.
This segment also offers various individual, small group, and large group commercial healthcare products to employers and directly to members in the Managed Care segment.Its Specialty Services segment provides pharmacy benefits management services; health, triage, wellness, and disease management services; and vision and dental, and management services, as well as care management software that automate the clinical, administrative, and technical components of care management programs. This segment offers its services and products to state programs, correctional facilities, healthcare organizations, employer groups, and other commercial organizations. The company provides its services through primary and specialty care physicians, hospitals, and ancillary providers. Centene Corporation was founded in 1984 and is headquartered in St. Louis, Missouri.
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IndustryHealthcare
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No. of Employees47, 300
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Website
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Jobs Posted349
