Reviewer

• Coordinate, integrate, and monitor utilization of physical health medical and healthcare services
• Perform pre-service, concurrent, and post-service clinical reviews
• Determine appropriateness and medical necessity of requested services using clinical criteria, medical policies, contractual benefits, and mandates
• Refer appropriate cases and potential quality-of-care or utilization issues to the Medical Director
• Coordinate with Case Management to address member needs and prevent gaps in care
• Conduct reviews telephonically, electronically, or on-site according to customer and departmental needs
• Plan, implement, and document utilization management activities
• Communicate with members, treating physicians, and other providers to obtain clinical information and facilitate needed services
• Collaborate with hospitals, home care, care management, and other providers
• Serve as a resource and liaison to the provider community with Provider Relations
• Interpret clinical criteria, medical policies, contract benefits, and State and Federal Mandates
• Price, code, and research claims as needed
• Meet departmental timeliness, production, metric, and audit requirements
• Maintain regulatory and accreditation compliance and implement changing requirements
• Participate in rotating on-call coverage and perform additional hours as required
• Assist with training and special projects
• Level II: Suggest process improvements, mentor staff, manage complex assignments, participate in committees, and lead when required
• Level III: Provide leadership, identify process efficiencies, maintain procedures, serve as escalation subject matter expert, mentor staff, back up the Supervisor, support orientation and training, and assist the Medical Director with projects

Explore Utilization Management Reviewer, RN – SN LTSS, Duals at LTHC. Review requirements and application details.