Reviews prior approvals, inpatient and outpatient services, procedures, network exceptions, and other requests to assess medical necessity and appropriate levels of care using evidence-based criteria and applicable policies. Collaborates with providers and internal staff, documents determinations, handles calls and queues, and promotes quality, patient safety, accessibility, and cost-effective care.
The Chart Procurement Analyst coordinates the retrieval, organization, and analysis of medical records to support risk adjustment and quality initiatives. They act as a liaison between healthcare organizations, vendors, and internal departments to streamline data collection and provider communication.
The Claims Specialist is responsible for resolving medical claims that are not automatically adjudicated by the system to ensure accuracy and timeliness. This involves investigating issues, communicating with providers, and maintaining compliance with departmental quality and productivity standards.
The RN Case Manager assesses, plans, and coordinates comprehensive care plans to optimize patient outcomes and resource utilization. They serve as a liaison between patients, families, and healthcare providers to ensure cost-effective and appropriate service delivery.
The Claims Specialist is responsible for resolving medical claims that are not automatically adjudicated by the system to ensure accuracy and timeliness. This involves investigating issues, communicating with providers, and maintaining compliance with departmental quality and productivity standards.
The RN Case Manager assesses, plans, and coordinates comprehensive care plans to optimize patient outcomes and resource utilization. They serve as a liaison between patients, families, and healthcare providers to ensure cost-effective and appropriate service delivery.
The Software Administrator is responsible for designing, deploying, and maintaining assigned systems while ensuring operational efficiency. They consult with users to identify procedures, manage software upgrades, and maintain comprehensive project and system documentation.
The Utilization Management Nurse performs clinical reviews of prior approvals, admissions, and procedures to assess medical necessity and appropriateness of care. They collaborate with healthcare providers and internal staff to promote quality, cost-effective care while ensuring compliance with clinical guidelines and regulations.
The RN Case Manager assesses, plans, and coordinates comprehensive care plans to optimize patient outcomes and ensure cost-effective healthcare delivery. They serve as a liaison between patients, families, and healthcare providers to facilitate appropriate services and maintain compliance with regulatory standards.
The RN Utilization Management Nurse performs clinical reviews of prior approvals, medical necessity, and benefit inquiries to ensure appropriate and cost-effective care. This role manages incoming and outbound calls and documentation while adhering to clinical guidelines and regulatory standards during both regular and weekend shifts.
The Clinical Pharmacist will supervise drug utilization and prior authorization programs while developing pharmacy cost containment strategies. They will also serve as a corporate resource to medical management and operations staff regarding pharmacy policies and procedures.
