Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.
80% of position responsibilities include:
Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. Provides education to members and their families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made.
Other responsibilities include, but are not limited to:
10% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
10% Participates in quality control activities in support of the corporate and team-based objectives. Participates in all required training.
Position is remote, BUT candidate must live within 2-3 hours of Columbia, South Carolina.
Bachelor's degree - Social Work OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing (Required)
2 years clinical experience (Required)
Active, unrestricted LPN/LVN licensure from the United States and South Carolina, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in South Carolina (Required)
Proficient knowledge of Microsoft Office, including Excel and Outlook (Required)
Good verbal and written communication skills
Experience handling confidential or sensitive information (Required)