• Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting. Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts.

• Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review

• Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.

• Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as noted above, but excludes denial determinations.

• Process incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization. Verify benefits and/or eligibility information. Check benefits for facility-based treatment.

• Review of information and summarization of member's potential care needs and/or durable medical equipment (DME) needs following discharge and forward to client for final discharge plan.

• Conduct PSCCR claims review utilizing the member's benefit contract and health plan guidelines.

• Consult with clinical reviewers and/or U.S. - licensed medical directors to approve medically appropriate, high quality, cost effective care throughout the PSCCR process.

• Facilitate accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

• Determine contract and benefit eligibility; obtain intake (demographic) information from callers and/or faxes.


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