Job Description

• Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity.
• Performs utilization review in accordance with all state mandated regulations.
• Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.
• Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers.
• Completes documentation of review and denial processes in the EPIC Case Management Module
• Responds to requests from the payer for all required information and treatment plans.
• Reviews and validates physician’s orders, reports progress and unusual occurrences on patients to the payer.

 

• Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently. 

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