The Case Management RN coordinates care for members with complex health needs by developing and monitoring member-centric care plans. They also serve as a liaison between members, families, and providers while managing utilization and prior authorizations.
Review medical and behavioral health service requests for appropriateness and medical necessity using evidence-based criteria, authorize appropriate services, and refer questionable cases to medical directors. Manage the utilization review queue, analyze utilization trends, support process improvements and compliance, and potentially cross-train in case management.
The Claims Examiner III investigates potential fraud, waste, and abuse within the Military Veteran Health program by analyzing medical records and utilization patterns. They also perform pre-payment and post-payment reviews to ensure medical necessity and compliance with program policies.
