Performs Treatment Authorization Request (TAR) review and appeals to determine medical necessity, appropriateness of services, interprets benefits and limitations, and reviews claims, which are questionable in dollar amount or volume or scope of services. Assures that care is at all times at an acceptable level of quality.
Interviews and participates in the selection of qualified candidates for open positions within the claims operations area. Evaluates performance and provides developmental opportunities for claims staff. Counsels performance issues when needed. Reviews and signs time cards.
Provide proactive monitoring of UNIX/Amisys systems environment and problem resolution, user support, printing support, system application support, Operating System support, hardware/software system installation, configuration and maintenance.
Develops and oversees administration of the Plan's Quality Assurance efforts for the provision of behavioral health care services including identification and review of potential quality issues and development of clinical practice guidelines and associated trainings. Confers with and counsels participating clinicians as needed to address patterns of utilization. Assures that behavioral health care is at an acceptable level of quality at all times.