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POST DATE 8/15/2016
END DATE 12/19/2016
JOB DESCRIPTION- Conducts pre-service, concurrent/ retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Service requests may be from electronic transmission, inbound calls and facsimile
- Makes outbound calls to the provider as required to gather additional information that may be needed
- Utilizes client specific criteria sets, applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to the clients nursing reviewer and/or clients medical staff for review
- Conducts any utilization or medical management review activities which require the review of clinical information against client specific criteria as noted above, but excludes denial determinations
- Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract
- Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process
- Collaborates with providers to assess members, needs for early identification of and proactive planning for discharge planning
- Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting