Shift Timing: Shift is Monday - Friday 8:00am - 5:00pm or 8:30am - 5:30om
Job Summary
Walk me through the day-to-day responsibilities of this the role and a description of the project (Outside of Workday JD):
Review for medical necessity-based on the criteria available
Promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.
Works with healthcare providers and authorization team to ensure timely review of services and/or requests to ensure members receive authorized care.
Coordinates as appropriate with healthcare providers and interdepartmental teams, to assess medical necessity of care of member.
Escalates prior authorization requests to Medical Directors as appropriate to determine appropriateness of care.
Assists with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
Collects, documents, and maintains all member’s clinical information in health management systems to ensure compliance with regulatory guidelines.
Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high quality and cost-effective medical care to members.
Provides feedback on opportunities to improve the authorization review process for members.
Reviewing clinicals for procedures against the medical policies to determine medical necessity.
Describe the performance expectations/metrics for this individual and their team:
Quality and production metrics must be met to be successful.
Tell me about what their first day looks like:
The nurse will complete approx. four wks of corp training and then work 1:1 with a nurse on our team.
What previous job titles or background work will be in this role?
Requires PA experience or experience in MM or UM experience.
Candidate should have experience in a remote role.
Red Flag-Case managers do not seem to do well in this role-manager prefers not to receive Case managers.
Seniority level
Entry level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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