Works with the Utilization Management team and is primarily responsible for prior authorizations. According to guidelines provides inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing Healthcare members with the right care at the right place at the right time. Assesses services for Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Provides prior authorizations according to policy.
• Identifies appropriate benefits, eligibility, and expected length of stay (as appropriate) for members requesting new treatments and/or procedures.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for embers including Behavioral Health and Long Term Care.
• Maintains department productivity and quality measures.
• Attends regular staff meetings.
• Completes assigned work plan objectives and projects on a timely basis.
• Maintains professional relationships with provider community and internal and external customers.
• Conducts self in a professional manner at all times.
• Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
• Consults with and refers cases to medical directors regularly, as necessary.
• Complies with required workplace safety standards.