Role OverviewResponsible for clinical review of utilization requests and assessment and implementation of potential coordination of care opportunities for overall membership, institutionalized populations, high risk members, and other members identified with at risk or high utilization needs.
What You Will Do
Performs utilization review of outpatient and ancillary services, determines medical necessity and appropriateness of services, accurately documents all review determinations, and collaborates with physicians and other providers.
Why It Might Be a Fit
Requires strong oral and written communication skills, ability to reason logically, and excellent organizational skills.
Requirements
- Knowledge of managed care and associated group benefit plans
- Strong oral and written communication skills
- Ability to reason logically and use good judgment
- Knowledge of community-based resources
- Excellent organizational skills
- Proficient in Microsoft applications
- Excellent time management and documentation skills
- Successful completion of Health Care Sanctions background check
]]>