New York Utilization Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse I to provide clinical review for outpatient and ancillary services requiring authorization.

Key Responsibilities

• Conducts first level RN review for outpatient and ancillary prior authorization requests for medical appropriateness and necessity
• Completes data entry and correspondence related to each review, and documents rate negotiations accurately
• Acts as a liaison between TRICARE beneficiaries and providers, referring potential quality issues and suspected fraud cases to appropriate departments

Required Qualifications

• Active New York State clinical license
• Graduate of a Nursing program; BSN preferred, or a degree in Clinical Psychology or Clinical Social Work
• Three years of clinical experience in a healthcare environment; managed care experience is desirable
• NYS Driver's License or Identification card required
• For Fidelis Care only: NYS RN, OT or PT license required