Nurse Reviewer

Responsibilities Conduct preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services using appropriate policies, clinical and department guidelines. Collaborate with healthcare providers and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes and optimize member benefits. Perform routine reviews with limited or no previous medical review experience; receive guidance from senior colleagues and/or management. Partner with senior colleagues to complete non‑routine reviews. Conduct medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment. Requirements AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience providing an equivalent background. Current unrestricted RN license in applicable state(s) required. BA/BS degree preferred. Familiarity with Utilization Management Guidelines, ICD-10 and CPT‑4 coding, and managed health care including HMO, PO and POS plans strongly preferred. Previous utilization and/or quality management and/or call center experience preferred. Core Competencies Demonstrates expertise in conducting medical necessity clinical screenings and preauthorization reviews for diagnostic imaging services, ensuring compliance with Utilization Management Guidelines and optimizing member benefits. Strong collaboration with healthcare providers to promote high-quality outcomes is essential. #J-18808-Ljbffr Jobtailor