Responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.
Primary duties may include, but are not limited to:
Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.Applies clinical knowledge to work with facilities and providers for care coordination.May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines.
Qualifications
Requires a LPN, LVN, or RN; 2 years of clinical or utilization review experience; managed care experience; preferred or any combination of education and experience, which would provide an equivalent background. Current unrestricted license or certification in applicable state(s) required.
Primary duties may include, but are not limited to:
Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.Applies clinical knowledge to work with facilities and providers for care coordination.May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines.
Qualifications
Requires a LPN, LVN, or RN; 2 years of clinical or utilization review experience; managed care experience; preferred or any combination of education and experience, which would provide an equivalent background. Current unrestricted license or certification in applicable state(s) required.