Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting.
Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility benefits, and contracts.
Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as noted above but excludes denial determinations.
Ensure member access to medically necessary, quality he...