Performs Utilization Management review in accordance to federal and state mandated regulations, HUM URAC standards and client requirement and/or policies.
Maintains compliance with regulatory changes affecting Utilization Management.
Reviews the clinical information and treatment requests against established clinical review criteria, and determine if the criteria is met or not.
Documents review.
Protects and secures member’s Protected Health Information (PHI).
Responds to inbound calls pertaining to reviews in a timely manner, following client-established protocols.
Participates in discussion rounds with the Medical Director.
Arrives at a medical necessity decision conducting one of the following:
Nurse approves requests that meet the criteria
Nurse contractually denies requests excluded in member contract