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Associate-Clinicians-Nurses
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- Provide review of precertification requests for medical necessity basing from clinical policy guidelines
- Responsible for checking of eligibility and benefits of the member’s coverage
- Data gathering of additional information needed in reference to the guidelines, through effective communication with network providers as well as members
- Give unbiased recommendation for medical necessity based on medical records provided by the requesting parties
- Independently work with Medical Directors on referrals of cases that would not meet set guidelines upon initial review
- Review appropriate length of hospital stay utilizing Milliman Care Guidelines
- Efficient and timely review of cases with adherence to standards for urgent and non-urgent turnaround time
- Proactively offer peer to peer review and appeals process for reconsideration on case denials
- Maintain privacy of records for all related information to members
- Establish effective multitasking and task prioritization
- Work comprehensively within the turnaround time
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