RN Reviewer, Health Plan/Utilization Mgmt.
Core
Coordinate efficient utilization of health care resources for CCHP members, focusing on Behavioral Health and outpatient procedures.
Role type
Utilization Management RN Reviewer
Builds
Authorizes requested services and facilitates care transitions for health plan members
Domain
Health Insurance / Utilization Management
Deliverable
client delivery
Required skills
Clinical assessment, medical necessity determination, regulatory compliance, provider communication, electronic platform navigation, prioritization
Preferred skills
Critical care experience, discharge planning, Behavioral Health experience
Technologies
Electronic platforms and systems
Responsibilities
Assess member clinical information to determine medical necessity and appropriateness of services; authorize requested services using approved clinical criteria; communicate with providers to facilitate care transitions; ensure adherence to timeliness standards for authorization and adverse determinations
Seniority
Mid-level, hands-on IC