Nashville, United States
11 months ago
- *Please do not submit any candidates previously rejected on Req #9203950 *
Responsible for collaborating with healthcare providers and members to optimize member benefits and to promote effective use of resources. Assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services. May also manage appeals for services denied. May conduct pre-certification, concurrent and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts. May be responsible for day-to-day operations of a single or multiple IPA/IPOD and staff, and may serve as liaison with the local health plan to ensure continuity for IPA/IPOD members. Essential Duties and Responsibilities:
Responsible for the effective and sufficient support of all Utilization Management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.
Uses an established set of criteria, evaluates and authorizes the medical necessity of some inpatient and outpatient services.
Notifies provider of recommended changes in level of care.
Evaluates cases for quality of care and documents quality issues.
Issues letter to provider and member if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet certification criteria, and may issue denial letters.
May participate or assist in the planning of team, UM/QM, PCP, IPA and or Health Plan meetings. Works with management team to achieve financial goals and operational objectives