Nurse Reviewers will be responsible for conducting preauthorization, out of network and appropriateness reviews of treatment plans utilizing appropriate policies, clinical and department guidelines. They will collaborate with healthcare providers and members to ensure that patients are receiving high-quality care and clinically effective cancer treatments to optimize member benefits.
Oncology Nurse Reviewers:
Receive preauthorization requests from front-line intake specialists through direct call transfer.Conduct initial medical necessity clinical screening.Determine if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.Conduct initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.Verbally notify ordering physician or rendering service provider office of the preauthorization determination decision.Document the results of the initial clinical review and determination in the precertification computer system.Request additional clinical information as applicable.Maintain telephone service standards in accordance with pre-established departmental performance metrics.
Qualifications
The qualified candidate will have:
Registered Nurse with a current, valid unrestricted license in CaliforniaPrefer current oncology certification from the Oncology Nursing Certification Corporation. This could be as an oncology certified nurse (OCN ), certified pediatric oncology nurse (CPON ), certified pediatric hematology/oncology nurse (CPHON ), advanced oncology certified nurse (AOCN ), advanced oncology certified nurse practitioner (AOCNP ), advanced oncology clinical nurse specialist (AOCNS ), or certified breast care nurse (CBCN ).Minimum of three (3) years recent clinical nursing experience in an ambulatory or hospital oncology setting.Familiarity with managed health care programs including HMO, PPO, and POSFamiliarity with Utilization Management Guidelines preferredFamiliarity with ICD-9 and CPT 4 coding preferredPrevious utilization and/or quality management and/or call center experience helpfulCandidates should have good computer skills and solid typing speed and accuracy
Oncology Nurse Reviewers:
Receive preauthorization requests from front-line intake specialists through direct call transfer.Conduct initial medical necessity clinical screening.Determine if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.Conduct initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.Verbally notify ordering physician or rendering service provider office of the preauthorization determination decision.Document the results of the initial clinical review and determination in the precertification computer system.Request additional clinical information as applicable.Maintain telephone service standards in accordance with pre-established departmental performance metrics.
Qualifications
The qualified candidate will have:
Registered Nurse with a current, valid unrestricted license in CaliforniaPrefer current oncology certification from the Oncology Nursing Certification Corporation. This could be as an oncology certified nurse (OCN ), certified pediatric oncology nurse (CPON ), certified pediatric hematology/oncology nurse (CPHON ), advanced oncology certified nurse (AOCN ), advanced oncology certified nurse practitioner (AOCNP ), advanced oncology clinical nurse specialist (AOCNS ), or certified breast care nurse (CBCN ).Minimum of three (3) years recent clinical nursing experience in an ambulatory or hospital oncology setting.Familiarity with managed health care programs including HMO, PPO, and POSFamiliarity with Utilization Management Guidelines preferredFamiliarity with ICD-9 and CPT 4 coding preferredPrevious utilization and/or quality management and/or call center experience helpfulCandidates should have good computer skills and solid typing speed and accuracy