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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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