RN Utilization Review/ Referral Management
SUMMARY: Registered Nurse will provide Referral Management (RM) activities include timely processing of Right of First Refusal (ROFR) requests, screening of specialty care referrals, sustaining up-to-date MTF/ Managed Care Support Contact ( MCSC ) Memorandums of Understanding (MOUs), comply with Referral and Authorization Business rules, tracking, accounting, and resulting of referrals, and full use of RM information management systems. Individual will conduct reviews for medical necessity, pre-authorization, medical appeals, collection and recovery from insurance carriers, and right of first refusal activities. Must be familiar with Tri-Care.
Education- Baccalaureate of Science in Nursing from an approved National League of Nursing.
Experience- 6 years of clinical nursing experience is required. One year of previous experience in Utilization
Management is required. Full time employment in nursing field withing the last 36 months is mandatory.
LICENSE/CERTIFICATION- Current, active, full and unrestricted License to practice Nursing in accordance with State Board requirements. Nurse applicants must be a current U.S. licensed Registered Nurse. License can not be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/ certification agency.
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San Antonio, TX
Mon, 24 Jul 2017 15:24:38 PDT