Roles and Responsibilities
- Prepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions. Presents recommendations based on clinical review, criteria, and organizational policies to physician reviewers for final determination.
- Conducts prior authorization, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of care by applying MCG guidelines, medical policy, and benefit structure for defined service requests.
- Monitors clinical quality concerns, make referrals appropriately, identify and escalate care quality issues, and quickly identifies outlier cases, long length of stay cases or complicated prior authorization requests.
- Ability to interact with external facility or providers as needed to gather clinical information to support the medical necessity review process and plan of care.
- Assists departmental staff with issues related to coding, medical records/documentation, pre-certification, reimbursement, and claim denials/appeals.
- Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, courteously, professionally and document accordingly that can build patient trust and engagement.
- Effectively assess and facilitate appropriate utilization of clinical programs and/or discharge planning by thoroughly assessing and screening for proper care coordination following discharge.
- Effectively manages escalations within the department by ensuring appropriate accountability, sense of urgency, communication and follow through to closure.
- Ability to assist and facilitate working relationship with Medical Director on CM and UM cases.
- Demonstrates personal responsibility and accountability by meeting attendance and schedule adherence expectations with positivity, enthusiasm, and helpful personality.
- Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins, efficiently answering and documenting member/provider calls.