Case Reviewer - NP/PA
Core
Conducting pre-authorization, out-of-network, and appropriateness reviews for tests, medications, procedures, and surgeries to ensure medical necessity and optimize member benefits.
Role type
Licensed clinical case reviewer (NP/PA)
Builds
Pre-certification decisions and medical necessity determinations for healthcare services
Domain
Health insurance utilization management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical screening, medical necessity determination, policy/guideline application, system documentation, grievance/appeals review, collaboration with Medical Directors
Preferred skills
Utilization management experience, complex UM reviews, appeals/disputes/audits experience
Technologies
Pre-certification systems
Responsibilities
Receive pre-authorization requests from intake and nurse reviewers; Conduct initial medical necessity clinical screenings; Determine if initial clinical information meets medical necessity criteria; Work with Medical Directors to review and recommend on medical necessity; Document review results in the pre-certification system; Review out-of-network pre-authorization requests; Conduct review of grievance and appeals requests
Seniority
Individual Contributor, Licensed Professional