The Medical Review Coordinator reviews medical data and determines certification decisions for precertification cases in accordance with company and URAC standards. They also coordinate with utilization review specialists and physician advisors to ensure timely clinical documentation and case management.
The Medical Review Specialist conducts utilization reviews to confirm the medical necessity of hospital admissions and outpatient procedures. They manage clinical data, coordinate with providers, and ensure compliance with URAC standards and federal guidelines.
The representative will respond to member and provider inquiries regarding health benefits and precertification while negotiating rates with out-of-network providers. They are also responsible for documenting calls, managing electronic web-certs, and verifying patient and provider information.
The Case Manager manages an individual caseload to meet customer needs, including authorizing services and reviewing treatment plans for medical necessity. They coordinate care transitions, collaborate with healthcare teams, and maintain accurate documentation within the computer system.
The Case Manager manages an individual caseload by assessing patient needs, developing care plans, and coordinating with healthcare providers and payers to ensure quality care. They are responsible for documenting case actions, maintaining billing, and negotiating with providers to maximize medical benefits.
The Case Manager manages an individual caseload by assessing patient needs, developing care plans, and coordinating with healthcare providers and payers. They are responsible for reviewing medical necessity, maintaining case documentation, and ensuring quality care through ongoing communication and resource navigation.
