Nurse Reviewers are responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging and other services by utilizing appropriate policies, clinical and department guidelines. They collaborate with healthcare providers to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits.
Primary duties may include, but are not limited to:
Receives preauthorization requests from front-line intake.Conducts initial medical necessity clinical screening.Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.Conducts initial medical necessity review of out of network preauthorization requests for services requested outside of the client health plan network.Notifies ordering physician or rendering service provider office of the preauthorization determination decision.Documents the results of the initial clinical review and determination in the precertification computer system.Maintains confidentiality of patient and provider specific information.Develops telephone service standards to meet departmental performance metrics.
Qualifications
The successful candidate will have
IL State LPN licensure.1 year of experience;or any combination of education and experience, which would provide an equivalent background.Current unrestricted license in applicable state(s)Candidates should have good computer skills and solid typing speed and accuracy.Customer service experience would be helpful.Quality management and/or call center experience helpful.Previous clinical experience in a hospital or urgent care environment would be a plus, but not required.Familiarity with managed health care programs including HMO, PPO, and POS be a plus.Familiarity with ICD-9 and CPT 4 coding would be a plus
Primary duties may include, but are not limited to:
Receives preauthorization requests from front-line intake.Conducts initial medical necessity clinical screening.Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.Conducts initial medical necessity review of out of network preauthorization requests for services requested outside of the client health plan network.Notifies ordering physician or rendering service provider office of the preauthorization determination decision.Documents the results of the initial clinical review and determination in the precertification computer system.Maintains confidentiality of patient and provider specific information.Develops telephone service standards to meet departmental performance metrics.
Qualifications
The successful candidate will have
IL State LPN licensure.1 year of experience;or any combination of education and experience, which would provide an equivalent background.Current unrestricted license in applicable state(s)Candidates should have good computer skills and solid typing speed and accuracy.Customer service experience would be helpful.Quality management and/or call center experience helpful.Previous clinical experience in a hospital or urgent care environment would be a plus, but not required.Familiarity with managed health care programs including HMO, PPO, and POS be a plus.Familiarity with ICD-9 and CPT 4 coding would be a plus