Utilization Review Nurse

Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services. Answers Utilization Management directed telephone calls; managing them in a professional and competent manner. Processes all prior authorizations to completion utilizing appropriate review criteria. Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity. Acts as liaison between the TRICARE beneficiary and the Network Provider. Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and determination. Completes data entry and correspondence as necessary for each review.

According to JobzMall, the average salary range for a Utilization Review Nurse in 5130 Sunforest Dr, Tampa, FL 33634, USA is between $62,000 and $76,000 per year. Salaries can vary depending on experience and educational background.

Centene Corporation is a large publicly traded company and a multi-line managed care enterprise that serves as a major intermediary for both government-sponsored and privately insured health care programs.