The Review Nurse (UM) performs clinical reviews to assess medical necessity of a broad range of outpatient and inpatient services, while maintaining compliance with appropriate nursing standards and all regulatory requirements. Interfaces with medical directors, and both internal and external stakeholders, with regard to coverage for services, contract benefits and alternate resources available. This position interfaces frequently with treating providers in the gathering of clinical information and may also provide education on the medical review process. The review nurse makes coverage decisions based on Milliman criteria, nursing judgment and member contract coverage. Frequently collaborates with Fidelis medical directors in determining coverage of requested services; Interacts with members to assist with accessing appropriate resources for requested services.
- AA/AS - Associates Degree or equivalent required.
- BA/BS - Bachelors Degree or equivalent preferred.
- NYS RN Licence required.
- 2-3 years Medical/Surgical experience required.
- 3-5 years experience in Managed Care / Health Insurance preferred.
- Discharge planning or Utilization Management experience is required.
- Facets Experience preferred.