Referral Nurse

The Referral Nurse is responsible for providing support to health network providers. Responsible to review Treatment Authorization Requests (TAR's)/Cerecons requests for approval, modification and works with Medical Director daily on denials and medical necessity reviews.

Review of referrals to determine approval, modification or denial of services. Assure that utilization of referrals is completed within the proper time frames as specified by ICE and department standards.|Use appropriate criteria and document reasoning in IDX notes. Critical thinking must be applied to each decision made. Ability to make independent decisions based on job knowledge or criteria. Identification of out of area providers and non-covered benefits. Ensure that correct supporting documentation is obtained to resolve referrals in a timely manner. Ensure the denial and appeal process is followed. Assist with education to providers regarding non-covered benefits, use of contracted providers and ancillary services. Consult with Medical Director for all possible denial of service and ensure required time-frame is sufficient for the Medical Director to make a decision in required time frame. Assist with PMM's (claims review) daily and provide determination on approval or denial review for daily check run. Identifies and refers cases appropriately for CCS, Homebound, High Risk, QI and Health Education, per policy, and documents referral in case file.